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Personal Information Patient's Full Name:
Date of Birth:

Social Security Number (Optional):
Address:
Phone Number:
Email Address:

Medical Records Request Specific Date Range of Records Requested:
Name of Medical Facility/Provider:
Address of Medical Facility/Provider:

I authorize the release of my medical records, including psychological reports, to the requesting law firm.
Digital Signature (Type Full Name):
Date of Authorization:

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HDA Medical Demand Letter Intake Form

Welcome to our online hub. This is our secured site designed to keep your information safe while it is being transmitted to us. This will all but guarantee that only appropriate staff (and yourself) will see this information.