Requesting your Medical Record is quick and easy with Records Bank secure online HIPAA Compliant system.
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Just fill out the areas marked from Section 1 to 7;
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When complete, please use your mouse, stylus, or finger to sign your name for your e-Signature;
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At the bottom of the Form, click on the SUBMIT button. If you missed some fields, it will be highlighted in RED;
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You will be directed to a SUCCESS Page where you can securely make payment for the request with PayPal or any major credit card . If you would like to make payment over the phone or by cheque you will be prompted on how to contact us.
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Wait for a message from Records Bank on the status of your Medical Record Request. We will email you at the requester's email address entered below.
* NOTE: If you are unable to use our online Request & Authorization form below, please click on our FORM, print and fax directly to us at (702) 431-3355. You may also email a scanned version to info@recordsbank.org