Medical Records Release Getting Your Medical Records You stated that you are not currently in posession of your medical records. You can do one of two things: DO IT YOURSELF Visit each of your doctors and fill out a medical records release form Pay up to $1.50 for EACH page of your records Return to your doctor's and pick up your records OR HAVE US DO IT FOR YOU Fill out an online form Pay $0 to us for this service* Receive your records securely in your email *this $25 service is offered for FREE to our patients, however, some care providers may charge you a seperate fee. The state of Maine says that your marijuana doctor must review your past medical history before signing your recommendation. Obtaining your medical records is a VERY important step in the process. You can do one of two things: DO IT YOURSELF Visit each of your doctors and fill out a medical records release form Pay up to $1.50 for EACH page of your records Return to your doctor's and pick up your records OR HAVE US DO IT FOR YOU Fill out an online form Pay $0 to us for this service* Receive your records securely in your email *this $25 service is offered for FREE to our patients, however, some care providers may charge you a seperate fee. Your Medical Release Request has been accepted You may submit as many requests as you need.Get Me My Medical RecordsPersonal InfoName* First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone*Email*For notification of receipt of records Enter Email Confirm Email Medical Condition(s)Please enter your relevant medical conditions*In other words, the information you would like your doctor to send to our officeDoctor InfoMedical Facility*The name of your doctor's officeDoctor*Your doctor's nameDoctor Fax*VERY IMPORTANT! This fax number is the way that we will request your records from your doctor. If you do not have this number, you can either: --- Do a quick web search to find it --- Call your doctor's office and get itDoctor Phone*Other PermissionsOur goal is to obtain your medical records promptly; by initialing this box you will be providing us with permission to retrieve any and all medical records which may support your medical marijuana card application, this may include sensitive information such as HIV, Drug/Alchohol and Psychiatric. This information is to be used for the purpose of medical review and patient care.Initial Here* (Use your mouse or finger to actually draw your initials like you would on paper. To clear and start over, click the refresh icon in the lower right corner under the box.) SecurityPIN*Once we receive your records, we will need to secure them with a password in order to transfer them to you via email. Please choose a 4-digit PIN that you will remember (it can be anything from the last 4 digits of your social security, to your bank pin, to your year of birth, whatever, as long as you can remember it). This PIN will not be sent to you via email.Expiration: Unless revoked in writing, this authorization expires in 180 days from date of signature. Disclosure Statement: I understand that once the information is discussed pursuant to this authorization, it may be re disclosed by the recipient without the knowledge or consent of the "sender" or you. This information may not be protected by federal privacy regulations. Disclaimer: Your general medical information may contain references to your mental state, drug and alcohol conditions, or HIV status or sexually transmitted diseases. Release of this information in your general medical record requires additional authorized signatures. Fax/Email Authorization: I specifically give authorization to FAX/email my medical information. I understand the risk involved in faxing/emailing records and confidentiality at the receiving end cannot be guaranteed. All faxed/emailed information will contain a confidentiality statement and instructions for misdirected information. Agreement: By signing below you are agreeing that your medical records are to be retrieved from your past health provider and sent to you via email. The message will be secured with your 4 digit PIN. Signature*(Use your mouse or finger to actually draw your signature like you would on paper. To clear and start over, click the refresh icon in the lower right corner under the box.)More than one doctor? YES, I need to fill out another release form after this one NameThis field is for validation purposes and should be left unchanged.