Medical Record Request – HealthcareLive

Who Is Requesting These Records?

Select the option that best describes you — we'll show the correct form.

Legal / Insurance Representative Attorney, paralegal, insurance carrier, workers' comp carrier, government agency, or other authorized third party requesting records on behalf of a patient.

Patient / Patient Representative You are the patient, or a parent/legal guardian requesting your own records — for example, to share with a new provider or specialist.

RECORDS CUSTODIAN

The entity holding these clinical records

Medical Group Entity

EHR/EMR Platform

Address

Records Request Email

REQUESTING FIRM / ORGANIZATION

Legal, insurance, or other authorized entity

Firm / Organization Name *Required field

Contact Name *Required field

Title / Role *Required field

Email Address *Valid email required

Phone Number *Required field

Firm Address *Required field

Type of Requesting Entity * Required field

PATIENT INFORMATION

Must match records on file with HealthcareLive Medical Group

Patient First Name *Required field

Patient Last Name *Required field

Date of Birth *Required field

Last 4 of SSN (optional)

Assists with patient identity verification

Patient Last Known Address

Patient Employer

Assists with workers' comp & injury claim matching

Employer Phone

Treatment Dates From *Required field

Treatment Dates To *Required field

Types of Records Requested * Required field

Additional Details / Specific Records

REQUIRED AUTHORIZATION DOCUMENTS

Both documents required — requests without them will not be processed

Patient Authorization / HIPAA Release Form *

Drag & drop or browse files

Signed HIPAA Authorization / Patient ROI Form — PDF, DOC, JPG, PNG (max 10 MB)

A signed patient authorization is required before records can be released.

Engagement Letter / Representation Documentation *

Drag & drop or browse files

Signed engagement letter, retainer, power of attorney, or court order — PDF, DOC, JPG, PNG (max 10 MB)

An engagement letter or representation document is required.

CERTIFICATION & ATTESTATION

Must be acknowledged before submitting

I certify that I am duly authorized to request these medical records on behalf of the patient or as otherwise permitted by law. I attest that all information provided is true, complete, and accurate. I understand that HealthcareLive Medical Group, Prof Corp will not release records without valid patient authorization per HIPAA (45 CFR §164.508) and applicable state law. I acknowledge this page provides access to clinical medical records only. Submission of false information may subject me and/or my firm to civil and criminal penalties.

Sent to recordsrequests@healthcarelive.com. HIM team responds within 15 business days. Attach court orders for expedited matters.

REQUEST SUBMITTED

Your medical records request has been received. Our HIM team will respond within 15 business days.

MEDICAL RECORDS REQUEST

Who Is Requesting These Records?

RECORDS CUSTODIAN

REQUESTING FIRM / ORGANIZATION

PATIENT INFORMATION

REQUIRED AUTHORIZATION DOCUMENTS

CERTIFICATION & ATTESTATION

REQUEST SUBMITTED

RECORDS CUSTODIAN

YOUR CONTACT INFORMATION

RECORDS REQUESTED

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

SUPPORTING DOCUMENTS

CERTIFICATION & ATTESTATION

REQUEST SUBMITTED