Third Party Request (Legal and Insurance)

Third Party Request

This form is for authorized Third Party Requestors only. This form is intended for use by authorized third-party requestors, including:

Legal representatives or Insurance companies

Submitting court orders

Orders for seizures

Please refer to the Patient Request Form to request your own medical records or to transfer a family member’s records to a new health care provider.

1Patient Info

2Organization Info

3Final Step

Patient’s First Name*
First
Patient’s Middle Name
Middle
Patient’s Last Name*
Last
Patient’s Previous Names

eg. maiden names, nicknames, etc.
Patient’s Date of Birth*
Patient’s Personal Health Number (PHN)*

ie. CareCard Number
Patient’s Previous Doctor*

Name of doctor that created patient's records.
Organization’s Name*
Organization’s Email*
We will send confirmation and your invoice via email
Enter Email Confirm Email
File Number/Case Number
File Processing Fee
Price:
Credit Card*
Your credit card will be charged twice. The first charge will be the non-refundable $47.25 (GST included) request fee to process your request and review all documentation provided. If you proceed to the next page, this fee will be charged immediately. Should we have your requested records, your card will be charged a second time for the record transfer once the records are shipped. Record transfer costs depend on the size and the type of records. An invoice will be e-mailed to you.
Card Details
Cardholder Name
No Credit Card
- We do not have a Credit Card
*** Please note a credit card is required for the quickest transfer of medical records.
Send Cheque*
We understand the necessity for a Credit Card, but we still wish to proceed with the transfer of the medical records. We understand that without a credit card, this process is delayed and the process is not complete until MedRecords receives a cheque of $47.25 for the request. Please send cheque to:
MedRecords Distribution Association
PO Box 999
Stn. Main
Port Coquitlam, B.C.
V3B 6H9
- We agree with the above and will send in a cheque immediately

Third Party Request (Legal and Insurance)

Third Party Request

1. Provide Copies

2. Upload Letter

3. Processing Fee

4. Certified Copies