Retrieve Medical Records from a 3rd party

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In the event you need to gather medical records from a 3rd party (i.e., PCP), please complete this form to send an authorization request for the release of your client’s confidential medical information for proper documentation and continuity of care.

How the records retrieval process works

  1. The clinician will complete the required fields in the form mentioned above.
  2. The client will receive an email to complete their required fields upon submission.  Their required fields include:
    1. SSN
    2. Signature
  3. Once the client clicks “Finish,” a fax will automatically be sent to the 3rd party.  The Support Team will also be notified and will upload the completed sent document to the client’s file in TN.
  4. The 3rd party has a few options for sending us the client’s records. The support team will upload the client’s records (once received) in the client’s file in TN and will notify the provider that they are there.

Correct fax number format

Please note the format of the Fax Number: 2223334444.  The fax number must have this exact format to send the fax to the 3rd party for their records.

Medical Records Authorization & Request Form