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Medical Records Request

Accessing your personal health information has never been easier. Our secure Medical Records Request Form allows patients to request copies of their medical records quickly, safely, and conveniently. Whether you need records for a new healthcare provider, insurance purposes, or personal reference, our form streamlines the process while ensuring your information remains protected.​​​

Medical Records Request

Birthday
Month
Day
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I hereby authorize Heart & Mind Counseling Services to release my medical records as described below.

Records Requested:
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Month
Day
Year
Date Range End
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Day
Year
Purpose of Request

Important Privacy Notice:

I understand that my mental health records are sensitive and may contain information protected under state and federal law, including psychotherapy notes. By signing this form, I authorize the release of these records for the purpose stated above.


Fee Notice:

There may be a $25 processing fee for this request if permitted by law. Payment instructions will be provided before the records are released.

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