Request for Records - Please Read Instructions
An authorization form is required when you are requesting copies of medical records or asking that we disclose your health information to 3rd parties.
We cannot fulfill medical records requests via email or an online form. Therefore, please download the form, complete and return it via mail or our secure fax.
Authorization for disclosure of health information is not valid if one or more required elements are left blank. Failure to complete all required elements may result in a delay in processing your request. Provided the form is completed accurately and completely, all requested items should be delivered within 24-48 business hours.
Click on the attachment, print, complete and send the form to ExamVIP, Inc. at the contact information below:
ExamVIP, Inc.
434 Desoto Drive
New Smyrna Beach, FL 32169
(F) 866-410-1784 (P) 1-866-235-9112
We cannot fulfill medical records requests via email or an online form. Therefore, please download the form, complete and return it via mail or our secure fax.
Authorization for disclosure of health information is not valid if one or more required elements are left blank. Failure to complete all required elements may result in a delay in processing your request. Provided the form is completed accurately and completely, all requested items should be delivered within 24-48 business hours.
Click on the attachment, print, complete and send the form to ExamVIP, Inc. at the contact information below:
ExamVIP, Inc.
434 Desoto Drive
New Smyrna Beach, FL 32169
(F) 866-410-1784 (P) 1-866-235-9112
| Request for Records.doc |