Medical Records Release

Chief complaint Primary insurance

Insurance name

Primary policy ID Do you have secondary insurance?

Yes No

Secondary insurance

Insurance name

Secondary policy ID

Preferred day Preferred time frame Upload documents PDF or image files accepted (up to 10 files, max 10MB each)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

Chief complaint Primary insurance

Insurance company name

Primary policy ID Do you have secondary insurance?

Yes No

Secondary insurance

Insurance company name

Secondary policy ID

Upload insurance card PDF or image files accepted (up to 10 files, max 10MB each) — e.g. front and back of an insurance card

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

Before you submit

Your information must match our records. We only send an invitation once the name, date of birth, and email you entered match what we have on file.
Using a different email than the one we have on file? Check the box below. To protect your records, we'll call you at the phone number on file to confirm before we change it.
Already use this email at another practice on Tebra? Each email can be used on only one Tebra portal account. Add a plus sign and a tag before the @, like [email protected], enter that address above, and check the box below. Mail to it still arrives in your normal inbox.
Watch for an email from Tebra. After our staff review your request, the invitation comes from Tebra, our patient portal provider, not from our office. Please wait for it, and check your spam folder.

This is a new email address. Please update my record (you'll call the phone number on file to confirm first).

I understand an invitation is only sent once my information is confirmed against your records.

What's this about? What's your question? Upload a document (optional) PDF or image files accepted (up to 10 files, max 10MB each)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

Type of question Describe your question What action would you like us to take? Upload EOB or documents PDF, images, or Word documents accepted (up to 10 files, max 10MB each)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

What do you need?

Free — Send my records to another provider for my continuing care Fee applies — Send a copy to me, an attorney, SSA, VA, a disability office, or anyone else who isn't treating me

Fees apply. Our office will confirm the amount, based on your request, before releasing records. Records are sent electronically only, by secure email or fax. Getting your records yourself through the patient portal is always free.

Step 1: Print, sign, and scan the release form

We need a release form signed by hand (a typed or electronic signature can't be accepted). Download it, print it, fill it out, sign it in ink, then scan it or take a clear photo of every page.

Download the Continuing Care release form (PDF) Download the Medical Records Release form (PDF)

Send records to

Me, by secure email Someone else, by fax or secure email

Provider Receiving Your Records

Provider / facility name Fax number Location / address Phone number

Other Contact Details

Contact name Phone number Fax number Email Enter a fax number or an email address. We don't send paper copies.

Step 2: Upload your hand-signed release form Scan (PDF) or photo (JPG/PNG) of every signed page — up to 10 files, max 10MB each Anything else you'd like us to know? (optional)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request and that the uploaded release form has been signed by hand by the patient or authorized representative.

I understand fees apply to this request, that the office will confirm the amount, and that payment is due before records are released, and that I can get my records free through the patient portal instead.

Reason for this records request Upload your authority to request these records Signed patient authorization, subpoena, court order, or similar (up to 10 files, max 10MB each)

Patient Information

Whose records are you requesting?

Patient first name

Patient last name

Patient date of birth

Anything else you'd like us to know? (optional)

I confirm that I am legally authorized to request these medical records and that the uploaded document supports this request.

Document type

Insurance Card (Front & Back) New Patient Paperwork Existing Patient Paperwork Lab Results Other

Description of document(s) Upload scanned document(s) PDF or image files accepted (up to 10 files, max 10MB each) — select both sides if uploading an insurance card Anything else you'd like our office to know?

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

Patient Forms

Who is requesting these records?

Before you submit

Get your records free in the patient portal

Step 1: Print, sign, and scan the release form

Provider Receiving Your Records

Other Contact Details

Patient Information

Release Forms

Medical Records Release — Continuing Care

Medical Records Release — Paid