3rd Party Request to Access, Use, or Exchange Electronic Health Information (EHI)

(Not for Patient Use. Patients and their legal representatives should complete the Patient Request for Health Information Form found at

Questions? Call 866-609-4357. For patients 877-778-7211.
Requester Information
Request Information
If the request pertains to specific patients, please provide patient names, dates of birth, addresses, and/or other identifiers to facilitate patient matching.