Medical Records Request - HIPAA Compliant Release of Information Software

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First Name

Middle Name (optional)

Last Name

Email address

Confirm Email address

Password

Password must meet all requirements:

Minimum 8 characters
At least one lowercase letter (a-z)
At least one capital letter (A-Z)
At least one number (0-9)
At least one symbol (!@#$%^&*)

Confirm Password

Name	Address

Does your organization provide healthcare services to Patients directly? Yes No

Select your organization type

Organization Name

Organization Address Line 1

Organization Address Line 2 (optional)

City

State

Zip

Fax #

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Phone Number on account Mobile Home Work or Other

By providing your telephone number you authorize ChartRequest to contact you via text messaging for purposes relevant to your account or ChartRequest’s services, such as billing reminders, maintenance notifications, payment confirmations, etc. Your consent is not a condition of purchasing any of ChartRequest’s goods or services. Message and data rates may apply. You may opt out at any time by visiting your account and updating your preferences or replying STOP to any message received. View our T&C here.

Enter Valid Phone Number

How would you like to verify your account?

Call By providing your telephone number you authorize ChartRequest to contact you via text messaging for purposes relevant to your account or ChartRequest’s services, such as billing reminders, maintenance notifications, payment confirmations, etc. Your consent is not a condition of purchasing any of ChartRequest’s goods or services. Message and data rates may apply. You may opt out at any time by visiting your account and updating your preferences or replying STOP to any message received. View our T&C here.

Text By providing your telephone number you authorize ChartRequest to contact you via text messaging for purposes relevant to your account or ChartRequest’s services, such as billing reminders, maintenance notifications, payment confirmations, etc. Your consent is not a condition of purchasing any of ChartRequest’s goods or services. Message and data rates may apply. You may opt out at any time by visiting your account and updating your preferences or replying STOP to any message received. View our T&C here.

Email :

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ChartRequest is a centralized, HIPAA-compliant platform to exchange medical, billing, and imaging records between entities. Leverage our secure exchange platform to manage and audit with a high-level view of all record transactions.