Request Medical Records

/Request Medical Records
Request Medical Records 2018-05-23T07:58:03+00:00



Date of Birth

Requestor Information

Requestor Type







*if Attorney Requestor Type is selected, request must originate from the requesting attorney office on letterhead

Release Information



Delivery Method
Note that any requests sent via US Postal may be delayed by 2 - 3 weeks. There is no fee for Secure Electronic Delivery (Follow My Health Account no fee)
Documents to Include:
Office Visit Notes
Operative Report
EMG Report
Physical Therapy Report
CT Report
MRI Report
Radiology Images on CD ($10 fee)
Other: free text

Please select any information that you wish to be excluded Exclude HIV / AIDSExclude Sexually Transmitted DiseaseExclude Mental Health TreatmentExclude Drug / Alcohol Related

By submitting this request you acknowledge that payment is required prior to release of records. An invoice will be sent to the email or fax number provided above. Delivery times are from the date payment is received.

Request an Appointment




Have you been seen at OCI before?

YesNo

Insurance Plan


Where you injured on the job? *

YesNo

Reason for your visit

Have you been seen for this problem before? *

YesNo

Please choose a physician for your visit

Please choose a location for your visit

What time would be better?

AMPM