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NON-MEMBER RECORDS TRANSFER

[Your Healthcare Company] makes it easy for you to transfer your medical records online. Simply enter the physician, institution/clinic and contact information for where we can access your medical records and we'll take care of the rest. You'll receive an email to confirm this request immediately and, upon transfer completion, you'll be notified of the successful transfer.
 

 
Patient Information
* Physician / Office
* First Name
* Last Name
* Last 4 Digits of SS#
* Birth Date
* Address 1
  Address 2
* City
* State
* Zip Code
* Country
* Phone Number
  Mobile Phone
* Email Address
     
 
Medical Records Location
* Physician
* Clinic Name
* Address
   
* Clinic Phone
* Needed for Date:  Date Needed
     

Important: If you receive any emails denoting a transfer request that you did not authorize or if this is an emergency, please contact [Your Healthcare Company] Support Line.
* Required Fields

 
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