Attorney Records Request Form - University Diagnostic Medical Imaging

Attorney Records Request Form

If you are an attorney and would like to obtain medical records on behalf of your client, please fill in the below form. 

Please be aware that UDMI takes its responsibility and duty to protect our patients’ private health information in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) seriously.  Accordingly, in addition to completing below, please provide (1) a signed and dated Authorization to Release Protected Health Information authorizing the release of medical records to you and/or your firm, (2) power of attorney, and (3) if relevant, guardianship records, Death Certificate, or Executor of Estate documents. 

Please take notice that UDMI will not comply with any request that is incomplete and/or inaccurate.

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Click here to download the HIPAA Authorization Form!
Please upload Completed HIPPA Authorization Form
Max. file size: 2 GB.