Enter Request Information
Upload Authorization
Review and Submit

New Medical Records Request

Clinics

Select / Update Clinics

Selected Clinic(s):

You currently have no clinics selected. Please select at least one clinic.

Patient Information

Patient Last Name:

Patient First Name:

Other Patient Names (Optional):

Patient Date of Birth:

Physician / Clinic (Optional):

Please select the visits/admissions you would like released:

Most recent

All

In a date range

Service Start:

Service End:

Please select the type of information you would like released:

Medical Records

Pertinent Information (Discharge Summary, History and Physical, Consultation, ER Reports, Labs, Radiology Reports, EKGs, Pathology Reports)

All health information pertaining to my medical history, mental or physical condition and treatment received, including records received from other healthcare providers. A reasonable clerical and reproduction processing fee is applicable.

Only the following records or types of health information included in the dates of service:

Emergency/Urgent Care Physician Report History and Physical Report Discharge Summary Report Consultation Report Operative Report Anesthesia Records Laboratory Reports Pathology Report Radiology Report Newborn Record Immunization Record Therapy Records

Itemized Billing

Radiology Images (The Radiology Department will follow up if any charges or additional information is required.)

Pathology Slides (The Pathology Department will follow up if any charges or additional information is required.)

Medical Records will be delivered electronically through this website.

Radiology CDs and Pathology slides will be sent via US Mail or can be picked up at the facility. You will choose below how you would like them delivered.

The following information will not be released unless specifically authorized by checking the relevant box(es) below:

Information pertaining to drug and alcohol abuse, diagnosis, or treatment

Information pertaining to mental health diagnosis or treatment

HIV/AIDS test results

Genetic testing information

Worker's Comp information

Note: Diagnostic Studies cannot be requested through this website. They must be requested by mail from the location where the study was completed.

Purpose of Request

Please enter your reason for requesting records.

Purpose:

Limitations, if any (Optional):

Your Information

Relationship to Patient:

Name:

Preferred Notification Method

Phone Number:

Type:

Retype Phone Number:

Email Address (Optional):

Retype Email Address:

Delivery Information

Delivery Method:

Radiology Images are saved to CD. Radiology Images and Pathology Slides can be either picked up by you at the facility, or delivered to you via US Mail.

Delivery Method:

Radiology CDs and / or Pathology slides will be delivered to the following address:

Address:

Line 2:

City:

State:

Zip:

Medical records will be delivered via this website in Adobe PDF format. A notification will be sent when the records are ready for download, and they will be available for 30 days.

Normal processing time is 5 business days from time of receipt. Please contact us if you have any questions.
Shasta Orthopaedics ROI Vendor: (530) 241-2971

Cancel

Continue

Delete this Request?

Are you sure you want to delete this request? This will stop all work on fulfillment and a new request will have to be entered.

Preferred Notification Method

This is the method by which you would like to receive automatic notifications of the progress of your request(s), as well as how you will receive password updates from this website. If we have specific questions about your request, we will call you at the phone number listed.

Please Select Clinics

Shasta Orthopaedics

Liberty Physical Therapy

North Valley Neurosurgery (Pre 02/01/2018)

Error

There has been an error processing your request. Technical support has been alerted, however additional information will help solve this issue. Please send some brief comments describing what you were doing:

Comments Submitted

Thank you for your comments. While waiting for technical support, please logout and log back in before retrying.