Request Records — Pivot Point Counseling

Records Request Form

Current and former clients may request a copy of their medical records by filling out this form. Please note that fees may apply for paper copies and multiple requests.

Client Name

First Name

Last Name

Name of person requesting records

Type "self" for both first and last name if over 18 and filling out this form for your own records

First Name

Last Name

Relationship to client

Enter "N/A" if self

Email

Email addresses that do not match an authorized email address on file may require further identification

Clinician Name:

Client Date of Birth

MM

DD

YYYY

Type of Records Requested

Full Medical Record

Clinical Records Only

Billing Records Only

Treatment Summary

Records are being released to:

Preferred Method of Delivery

Email

Fax

Mail *additional fees for paper copies and postage may apply.