Medical Records Request: Primary Care and Referring Providers Only

This form is for primary care physicians (PCPs) and referring providers only. Use it to request records for your patients, up to 20 patients at a time. Fields marked * are required.

Not the patient’s primary care or referring provider? Use the third party request form on the Medical Records Request page instead. Patients can request their own records there too.

Records are only sent if the requesting provider is the patient’s referring provider or primary care physician (PCP) on file. We compare the provider you enter below with what is on file for each patient. If it doesn’t match, we can’t send that patient’s records.

Requesting provider

Find the referring provider or PCP in the NPI Registry (optional)

Search the public NPI Registry to fill in the provider’s name, NPI, address, phone, and fax. You can edit anything afterward.

Provider’s first name Provider’s last name Title Provider’s NPI # (optional)

Provider’s address

Street address

Street address line 2 City State ZIP code

Email Phone number Fax number

Patients

Add each patient whose records you need. You can add up to 20 patients in one request. For more, send a second request.

Records requested

Types of records being requested Endoscopy/Colonoscopy/Procedure Reports Pathology Reports Imaging Reports Lab Results Consultation/Office Notes All Records

How do you want to receive the records? Fax Email (encrypted)

Fax requires a fax number above. Email goes to the address above.

Submitted by

Your first name Your last name Your title

Submitted securely to our office. Do not use this form for emergencies. Questions? Call 626.898.4560.

Medical Records Request: Primary Care and Referring Providers Only

Thank you! We received your request.