Medical Records Request Portal | Morgan Records Management

Provider/Medical Practice/Hospital

Select The State The Medical Practice is Located*

Select Medical Practice *

Patient Information

First Name*

Middle Name

Last Name*

Maiden Name

Date of Birth*

Alias/ Alternate Name/ Pet Name

Phone Number*

Contact Email Address*

Is This a Third Party Request

Provider/Company/Organization*

Reference

Reason for Request *

Medical Release

Continued Medical Care

Legal Purposes

Insurance Purposes

Personal Interest

Other:

Requesting Psychotherapy Notes*

Yes

Please Upload a Government-Issued Photo Identification (State Driver's License, State Issued Non-Driver's License, Passport, Military ID) or alternatively enter the last four digits of your social security number. For Third Party Request please upload the legal documentation requesting the records.*

Last 4 digits of Social Security Number: XXX-XX-

In order for us to disclose protected health information related to reproductive health care, the DHHS requires a completed attestation form. Please download, complete, and upload the form below *

Delivery Options

Secure HIPAA Electronic Transfer

Disc Mailed to Home or Physician - USPS

Pickup Disc In Person

USB Thumb Drive mailed to Home or Physician

Third Party EMR/System Upload

Send Fax

Send records to this email (Enter email to send files to) *

Confirm Send records to this email (Enter email to send files to) *

Shipping Address

Attention*

Company/Provider

Address Line 1*

Address Line 2

City Name*

State*

Zip*

Enter the credentials of where you would like the files uploaded:*

Url / Host*

Port

Username*

Password*

You have selected to pick up your medical records. Once your records are processed we will contact you to set up a pick up time.

We are located at:
Morgan Records Management
8 State Street
Nashua, NH 03063

Fax Number*

Select The State The Medical Practice is Located*

Select Medical Practice *

First Name*

Middle Name

Last Name*

Maiden Name

Date of Birth*

Alias/ Alternate Name/ Pet(s) Name

Phone Number*

Contact Email Address*

Is This a Third Party Request

Reason for Request *

Medical Release

Continued Medical Care

Legal Purposes

Insurance Purposes

Personal Interest

Other:

Requesting Psychotherapy Notes*

Yes

OR
Last 4 digits of Social Security Number: XXX-XX-

In order for us to disclose protected health information related to reproductive health care, the DHHS requires a completed attestation form. Please download, complete, and upload the form below *

HHS OCR Modal Attestation form Reproductive Health care use of Attestation

How does Morgan Records set request fees and why do I Have to Pay for Copies of My Records?

In accordance with HIPAA Privacy Rule 45 CFR § 164.524 , Morgan Records utilizes the “average cost” pricing method. Please note. This is not to be confused with charging a “flat fee” which is NOT how we set pricing. The fees cover our labor, supplies, and postage costs and ensures reasonable, compliant charges that offer the best value for all requesters.

Delivery Options*

Secure HIPAA Electronic Transfer

Disc Mailed to Home or Physician - USPS

Pickup Disc In Person

USB Thumb Drive mailed to Home or Physician

Send Fax

Send records to this email (Enter email to send files to) *

Confirm Send records to this email (Enter email to send files to) *

Attention*

Company/Provider

Address Line 1*

Address Line 2

City Name*

State*

Zip*

You have selected to pick up your medical records. Once your records are processed we will contact you to set up a pick up time.

We are located at:
Morgan Records Management
8 State Street
Nashua, NH 03063

Url / Host*

Port

Username*

Password*

Request Summary

Request	Quantity	Total	Actions

By clicking yes you agree to abide by the Terms of Service*

Signature*

Patients over the age of 18 must sign the release form. If a patient is unable to sign that is over the age of 18 please contact medical@morganrm.com or 833-888-0061 on how to proceed.

Do not sign this electronic form if you are not the patient.

I am the patient or legal guardian who has authorization to release the above records. Any facsimile, copy, or photocopy of this release will be valid for 90 days and shall authorize you to forward my medical records. This form gives you permission to share my private information obtained from this facility. Only records from this facility can be legally released. Any records from other physicians must be obtained from them directly.

I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.

Your files will be processed in the order they have been received and will be delivered based upon your delivery selection within 30 business days.

Please check your spam folder for records and other correspondence from us.

Submit Request Now and Pay with Credit Card

Morgan Records Management LLC adheres to strict industry standards for payment processing, including:

128-bit Secure Sockets Layer (SSL) technology for secure Internet Protocol (IP) transactions.
Industry leading encryption hardware and software methods and security protocols to protect customer information.
Compliance with the Payment Card Industry Data Security Standard (PCI DSS).

For additional information regarding the privacy of your sensitive cardholder data, please read the Privacy Policy.

Credit Card Number

Security Code

Expiry Date

First Name On Card

Last Name On Card

Submit Request Now and Please Invoice Me

Email Address to Send Invoice:

Attn: Morgan Records Management

8 State Street

Nashua, NH 03063

Please note this option does not submit the request and the completed form and payment must be sent to the above address. Checks made payable to Morgan Records Management

Provider/Medical Practice/Hospital

Patient Information

Request Summary

Signature*

Payment Information

Invoice

Order Summary