Third Party Records Request

THIRD PARTY RECORDS REQUEST
Fill out this form if you are an agency or individual requesting records for a Workit Health patient. Please be advised that submitting this form does not purport that the named patient is in our care, nor does it guarantee that any records will be sent to you. Your request will need further verification after form submission.
Your Name/Agency:*
Your Contact Phone Number:*
Please enter a valid phone number.
Your Contact Fax Number:
Please enter a valid fax number.
Your Contact Email Address:*
example@example.com
Which contact method do you prefer?

EmailFax
Patient Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
What records are you requesting?*

Substance Use Disorder Treatment RecordsRecords regarding Mental Health and Developmental DisabilitiesHIV-related test results and treatment informationOther: Please specify …
Date range to allow:*

All timeLast 30 daysOther: Please specify …
If you have an Authorized Disclosure for Release of Information (42 CFR Part 2) signed by the patient, please upload it here:

Cancelof
If you have other documentation to include, such as your own request form, please upload it here:

Cancelof
If you would like to leave any additional information, do so below, or email medicalrecords@workithealth.com.
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THIRD PARTY RECORDS REQUEST