Medical Records Request - Endless Mountains Health System - endlesscare 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the 'Patient Name' field, followed by your address and date of birth. Ensure all information is accurate for processing.
3. Select how you would like to receive your records by checking the appropriate box: Mailed, Fax’d (include fax number), or Picked up (provide name).
4. Fill in the 'FROM' and 'TO' sections with the relevant addresses for where the records are coming from and where they should be sent.
5. Specify the purpose of the request in the designated area, ensuring clarity on why you need these records.
6. Indicate which documents you wish to receive by checking the corresponding boxes and providing dates where necessary.
7. If applicable, initial next to any special authorizations required for sensitive health information.
8. Sign and date the form at the bottom. If signed by a legal representative, include their relationship to you.

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