1 Client Information

2 Power Of Attorney Or Legal Guardian (If Applicable) - Supporting Legal Documentation Required Indicating Relationship

3 Records Requested

4 Name Of Person/Company And Address Where Records Are Being Sent

5 Payment (For Medical History (MSP) Records Only)

6 Client Authorization - To Be Signed By The Client, Power Of Attorney, Or Legal Guardian

By clicking the [I confirm] button, I acknowledge that I am signing this form electronically and agree that this is the legal equivalent of my handwritten signature. I will not at any time in the future claim that my electronic signature is not legally binding. The date of my electronic signature is the same as my acknowledgement.