Medical Records Request Form

At Forge Health, we are committed to protecting your privacy and maintaining the highest standards of confidentiality. Please review the information below before submitting your request.

Important Information

  • We do not mail medical records.
  • Records can be sent via fax or encrypted email, based on your preference.
  • A signed Release of Information (ROI) is required to process your request.
  • If an ROI is not currently on file, please contact your office manager before proceeding.
  • Forge Health is fully HIPAA-compliant, and we take every measure to safeguard your health information.

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Request Details
Who is Requesting the Medical Records?*
*Information Required to complete a Release of Information form the client to sign
Patient / Client Name:*
*Information Required to Verify Client’s Chart
MM slash DD slash YYYY
Delivery Method
How would you like to receive the medical records?**
Note: We do not mail medical records.
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.
Record Details:
Select date MM slash DD slash YYYY
Select date MM slash DD slash YYYY
Briefly explain why the records are being requested (e.g., legal case, insurance claim, personal use).
0 of 255 max characters
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.