Medical Records Request Form

Request Details

Who is Requesting the Medical Records?*

The Patient / Client

Healthcare Provider

Family Member or Friend

Attorney / Legal Representative

Disability or Insurance Representative

Other

Your Name*

*Information Required to Verify Release of Information

First Last

Your Job Title:*

Your Organization*

Your Phone Number:*

Patient / Client Name:*

*Information Required to Verify Client’s Chart

First Last

Patient / Client Date of Birth*

Forge Health Office:

Delivery Method

How would you like to receive the medical records?**

Fax

Note: We do not mail medical records.

Fax Number*

If you selected Fax, please provide your fax number below:

Email Address:*

If you selected Email, please provide your email address below. Note: Records sent by email will be encrypted to ensure the protection of your information.

Authorization:

Do you have a Signed Release of Information?*

*HIPAA requires healthcare providers to protect a patient’s personal health information (PHI). Without written permission, PHI cannot be shared with anyone who is not directly involved in the patient’s care or legally authorized to receive it.

Yes – ROI is uploaded below

No – The client has not completed an ROI

Not Sure

Have you signed a Release of Information (ROI) with Forge Health?*

*To protect your privacy, federal law (HIPAA) requires that we keep your personal health information (PHI) confidential. This means we cannot share your medical records with anyone who is not directly involved in your care—unless we have your written permission. If you would like us to send your records to someone else (such as a family member, lawyer, or another provider), you’ll need to complete a Release of Information (ROI) form first. This process helps ensure that your information stays secure and only goes where you want it to. Let us know if you have any questions—we’re happy to help.

Yes – ROI has been complete.

No – I need to contact my Office Manager to complete the form

Not Sure

Record Details:

Date Range (From)*

Date Range (To)*

Purpose of Disclosure:

Briefly explain why the records are being requested (e.g., legal case, insurance claim, personal use).

Upload Medical Record Request / ROI (if applicable)

Note: A signed Release of Information (ROI) is required to process your request if one is not already on file.

Max. file size: 256 MB.

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