Medical Records Request - HIPAA Compliant Release of Information Software

We Care About Patients

First Name

Middle Name (optional)

Last Name

Date of Birth

Email address

Confirm Email address

Password

Password must meet all requirements:

Minimum 8 characters
At least one lowercase letter (a-z)
At least one capital letter (A-Z)
At least one number (0-9)
At least one symbol (!@#$%^&*)

Confirm Password

Name	Address

Phone Number on account Mobile Home Work or Other

By providing your telephone number you authorize ChartRequest to contact you via text messaging for purposes relevant to your account or ChartRequest’s services, such as billing reminders, maintenance notifications, payment confirmations, etc. Your consent is not a condition of purchasing any of ChartRequest’s goods or services. Message and data rates may apply. You may opt out at any time by visiting your account and updating your preferences or replying STOP to any message received. View our T&C here.

Enter Valid Phone Number

How would you like to verify your account?

Call By providing your telephone number you authorize ChartRequest to contact you via text messaging for purposes relevant to your account or ChartRequest’s services, such as billing reminders, maintenance notifications, payment confirmations, etc. Your consent is not a condition of purchasing any of ChartRequest’s goods or services. Message and data rates may apply. You may opt out at any time by visiting your account and updating your preferences or replying STOP to any message received. View our T&C here.

Text By providing your telephone number you authorize ChartRequest to contact you via text messaging for purposes relevant to your account or ChartRequest’s services, such as billing reminders, maintenance notifications, payment confirmations, etc. Your consent is not a condition of purchasing any of ChartRequest’s goods or services. Message and data rates may apply. You may opt out at any time by visiting your account and updating your preferences or replying STOP to any message received. View our T&C here.

Email :

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Tell us who your doctors are, and we will get your records for you. We make it easy to share your records with your care team. Leverage our Secure Storage Platform to keep all of your records in one place, forever.