Order Medical Records

This is where you can request medical records. Note you will be asked why you qualify to receive
these records, and you will be required to make the needed payment, once we deem you are entitled to what you
are requesting. We will then send a payment link, generally within one business day.

Please complete the following menu

Name of Requestor:

Company or Organization:

Name of Patient:

Patient Date of Birth:

Last 4 digits of Patient Social Security Number:

Your Phone Number with area code:

Your Email Address:

Your Fax Number:

Why are you entitled to these records?

Other – Explain:

Records Requested

Other – Explain:

Special Notes:

By clicking Submit you acknowledge you have the legal right to the records requested and have provided proof that the patient has authorized such a request. Once a number of available pages is determined you will receive a link to make the payment before delivery of requested data occurs.

www.northwestneurologymi.com

Order Medical Records

Please complete the following menu