Request Patient Medical Records - Jefferson Radiology

Request Medical Records

Please use the form below to request medical records. Your request will be securely forwarded to our medical records team for processing.

When picking up your records at one of our outpatient centers: Please allow three (3) business days before arriving at one of our locations to collect your records.
Mail Delivery: Please allow an additional 5-7 business days for shipping.

Attorney Requests for Imaging and CDs

To request CD medical records on behalf of your client, please complete the form below, ensuring all sections are filled out accurately.

Legal and Hospital Medical Records & Billing Requests

All legal medical records, hospital billing records, and billing statement requests must be submitted via ChartSwap or by contacting ChartSwap directly at 855-879-7927.
Important: Jefferson Radiology partners with a dedicated ChartSwap portal to securely process requests. If your firm uses ChartSwap, be sure to submit through the ChartSwap specifically connected to Jefferson Radiology. Requests sent through independently contracted ChartSwap accounts (e.g., ones initiated by your firm) are not processed by Jefferson Radiology and will result in delays.
We only provide imaging records for Jefferson Radiology, CT Imaging Partners, and Farmington Imaging Center. If your client received imaging services from a hospital or another provider, those records must be requested directly from the respective facility.

Processing and Delivery Timeline

Attorney requests are processed within 30 calendar days.
*Medical imaging CDs will be shipped via FedEx.

*Charges apply for legal medical records requests. Invoices will be faxed to the requesting attorney's office.

"*" indicates required fields

Attorney and Client Information Form

Attorney Full Name*

Law Firm Name

Attorney Email Address*

Attorney Phone Number*

Client Full Name*

Client Date of Birth*

Record Details

Enter the first date of the service

Enter the last of the service

Does this request include PHI related to reproductive health care? (e.g., abortion care, fertility treatment, contraception, prenatal care, etc.)*

Yes (requires attestation form)

No

Upload Attestation Form

Max. file size: 8 MB.

Download the required attestation form here.

Upload Patient Authorization Form

Drop files here or

Max. file size: 8 MB.

If you do not have a standard authorization form, you can download and use our JR Authorization Form here. Please ensure it is completed and signed before uploading.

Authorization Disclosures*

I authorize Jefferson Radiology to disclose the specified medical records to the recipient listed on this form.

I acknowledge the right to revoke authorization in writing.

I acknowledge that disclosed information may no longer be protected by HIPAA.

I understand that disclosed information may be redisclosed by the recipient and may no longer be protected by HIPAA or other privacy laws.

By selecting the boxes above, I confirm my understanding of the terms of this authorization.

This authorization will expire on:

A specific date:

The occurrence of an event (e.g., conclusion of legal proceedings).

If no expiration date or event is specified, this authorization will expire one year from the date of signature.

Please select a specific expiration date:

Describe the expiration event:

Additional Instructions or Notes

Digital Acknowledgment*

By checking this box, I confirm that I am the client or their authorized representative and that I authorize Jefferson Radiology to disclose the specified medical records as detailed above.

Name of Client/Representative:*

Date*

Relationship to Client (if applicable):

Need to Book An Appointment?

Check out our full list of services and call us at 860-289-3375 to get scheduled.

Our Services

Request Medical Records

Request Medical Records

Submit a Record Request

Attorney Requests for Imaging and CDs

Legal and Hospital Medical Records & Billing Requests

Processing and Delivery Timeline

Attorney and Client Information Form

Record Details

Need to Book An Appointment?

Our Partners