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Request Medical Records

Fill out the form to request your medical records.

Name of the Clinic

Who is the requester?Patient — $35Law Office — $55Medical Clinic / Hospital / Government — Free

Patient Name

Date of Birth

Delivery MethodFaxEmailPickup (at location)Delivery

Delivery MethodFaxEmail

Fax NumberWrite with Area Code in this format: (XXX) XXX-XXXX

Email AddressThis email address will receive the documents

Pickup LocationYou have to pickup documents from any of these locationsPalm Desert: 72650 Fred Waring Dr.Palm Springs: 1221 N. Indian Canyon Dr.Apple Valley: 18400 U.S. HWY 18.

Delivery TypeRegular Mail with tracking — FreeCertified Mail with tracking — $12.95FedEx/UPS — $29.95

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Signature

Start signing your signature here

Review Your Info

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Total Cost

$

Med Rec Black

MyMedicalRecords.co is a secure online service that helps individuals request and receive their medical records quickly and affordably. We believe everyone deserves easy access to their health information—anytime, anywhere.

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