Electronic Record Request Full Legal Name*Date of Birth (M/D/Y)*Phone Number*Please provide area code and extension if applicable Information Requested:*ie: Lab Results for the last 6 months; CT scans from Month/Year; or Surgical Notes from appendectomy on (date) Delivery Method* In-Person Pick Up (photo ID required at pick up) Forward Request (CMH will forward your record to another entity) Your privacy is one of our top priorities. Once we receive this request we will be in touch to verify the owner of the information is making the request.Name of Institution Receiving Records (if forwarding request)Phone Number of Receiving Entity: Before sending any medical records we will use this information to verify the request. Be sure to list any necessary extensions or name information that may be helpful. In the case you have requested that CMH forward your records, please provide a fax number and mailing address for the receiving facility.Information Needed By: (M/D/Y)Please allow up to a 6 week processing period for all Medical Record Requests. This iframe contains the logic required to handle Ajax powered Gravity Forms.