This system lets you as a patient or parent/guardian request that medical records be directed to a designated third party.
You will not be able to access those records yourself.
Only the third party will be able to access them through a secure website.
If you prefer to access the records yourself and then direct them to a third party in whatever way you wish, please click here to use the
short form for Urgent Care Group.
What You Need to Get Started
The patient's valid driver's license or other valid state-issued ID.
If you have the legal right to make healthcare decisions for a patient (custodial parent, legal guardian, healthcare trustee/conservator,
healthcare proxy, medical/healthcare power of attorney), you may place the request on behalf of the patient.
You must upload YOUR OWN Driver’s License/ID, the Driver’s License/ID of the patient (if patient is 18 years of age or older),
AND official documentation of your authority to make healthcare decisions for the patient.
NOTE: A financial power of attorney is not acceptable.
If you cannot provide ALL required items, the patient must place his or her own request.
A credit card to make payment
The name, address, and fax number of the third party to whom you are directing your records.
Please have these items handy before you start!
Important - Please Read!
To ensure patient security, we do not fax or mail paper records.
We use the third party's fax number only to send a notification to the third party to go online to access the requested records securely.
We cannot control when or if the third party listed on your request will access your records on our secure website.
You are solely responsible for any and all follow-up with the third party.
If you would rather access your records yourself and direct them to a third party in whatever way you wish, please click here to use the
short form for Urgent Care Group to have your records released directly to you.
You will be required to pay $25.00 for the processing of your request.
THERE ARE NO REFUNDS FOR ANY REASON WHATSOEVER.
NOTE: Third parties are not eligible to use this form to request records from Urgent Care Group.
Only patients or parents/guardians of patients are eligible to request records using this form.
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