Requesting your Medical Record is quick and easy with Records Bank  secure online HIPAA Compliant system. 

  1. Just fill out the areas marked from Section 1 to 7;

  2. When complete, please use your mouse, stylus, or finger to sign your name for your e-Signature;

  3. At the bottom of the Form, click on the SUBMIT button.  If you missed some fields, it will be highlighted in RED;

  4. 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.

  5. 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