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Third Party Request (Legal and Insurance)

Due to the coronavirus (COVID-19) outbreak, we are taking the recommended precautions for a safe work environment. Transfer times may be longer than expected. We appreciate your patience.

Third Party Request

This form is for authorized Third Party Requestors only (Legal/Insurance). If you are requesting your own medical records, please refer to the Patient Request Form.

If you are a Third Party requesting a copy of a medical record, please request your copies below. Please note the following:

1. Provide Copies

MedRecords provides copies of FULL medical records directly to an authorized requestor and does not fulfill partial medical record requests.

2. Upload Letter

You will be required to upload a copy of the patient’s signed authorization letter or court ordered authorization letter.

3. Processing Fee

There is a non-refundable fee of $36.75 per request (GST included). Payment for the FULL medical record copy is required before shipping.

4. Certified Copies

For medical-legal purposes please request a certified true copy. All other requests will be watermarked and may not be admissible.

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 $36.75 (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 $36.75 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