Download Medical Record Form

Full Name *

Phone *

Email *

I authorize Advanced Neurosurgery Associates to use the information I provide on this form to process my medical record request. I understand that this form may involve the exchange of Protected Health Information (PHI) and that such information will be handled in accordance with HIPAA Privacy and Security regulations. I acknowledge that this request is for my own medical records and may not be submitted on behalf of another individual without proper legal authorization.

By submitting this form, you agree to our Privacy Policy

Disclaimer: This form is intended solely for established patients of Advanced Neurosurgery Associates requesting access to their medical records. Please do not use this form if you have never been treated by one of our providers. For your protection, our office may contact you to verify your identity before releasing records. Processing requests may take 3–4 business days, and additional verification may be required