Get Patient Medical Record Request - Lrdc

Filling out the Patient Medical Record Request form is a straightforward process that allows you to request your medical records electronically or in printed form. This guide will provide clear, step-by-step instructions to ensure you complete the form correctly and efficiently.

Follow the steps to successfully complete your request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing the recipient’s details. Enter their name in the designated field, along with their phone number, which is required for pickup.
3. Fill in the street address, including any suite or apartment number, city, state, and zip code. This information is essential for accurate delivery.
4. Select your preferred delivery method by choosing one of the options: Email Delivery, Paper Delivery, or Pickup At Clinic.
5. If you selected Email Delivery, enter a valid email address where you would like the records sent. Ensure that this email is correct to avoid any delivery issues.
6. Now, provide the patient’s information. Enter the first and last name, followed by the date of birth in the specified format.
7. Indicate the records you are requesting by specifying the date range needed for these records.
8. Read the agreement regarding electronic delivery. Acknowledge by confirming that you understand the terms related to email delivery.
9. Sign the form in the designated requester's signature area and date it.
10. Once you have filled out all sections, you can save your changes, and then download, print, or share the form as needed.

Complete your Patient Medical Record Request online today to access your important medical information.