Medical Record Request

This Medical Record Request form is intended for patients or treating physicians. If you are not the patient or treating physician please fax your request on letterhead paper to (504) 883-3571.  Please be aware that all requests are verified by our staff in accordance with our patient privacy policies.

* If you need images within 48 hours, please call (504) 883-8111 (ext. 1011) after submitting your request.

Request Information

Type of Request:
ReportsCD (images and report)Film (may require fees)

Method of Delivery (Choose 1)
Fax Report OnlyPatient PickupSend via MailSend via Courier to Physician’s Office (may require fee)

Exam Type & Date Requested

Patient Information

Patient Name

Patient Date of Birth

Requester Information

Who is Requesting?
PatientReferring PhysicianOther

Name of Person Requesting Records

Phone Number

Email Address

Comments / Special Requests

Upload an Authorization Form (.PDF, .DOC, .DOCX, .PNG, .JPG accepted, 20MB limit)
If request is being made by a party other than the patient or referring physician

To prevent spam, please type the letters and/or numbers you see in the box below. If you need help, you can always call 504-883-8111.
captcha