Authorization Forms

It is the duty of ChartRequest and our Provider Clients to ensure that medical records remain confidential and that they are maintained and released in accordance with applicable laws.

If you do not have an Authorization form, you can find an authorization to release and disclose patient information form on the request page near the Upload Authorization button. Click on the "use this one" link after you login and you will be able to download that form and e-sigh. 

Please note you will have issues e-signing the form if you attempt to complete the form within your browser. Right-click and select "Save Link As" to download the form to your desktop. 

 

Please complete and upload this form so that our Provider Client and/or ChartRequest Staff can assist you!

Have more questions? Submit a request

1 Comments

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    tanya

    Tanya Orange 5/9/66 I authorize TO

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