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.

Before You Submit Your Request

Please review the options below to determine where your requests should be submitted based on the records you need.

Imaging reports only (CT Imaging Partners or Farmington Imaging Centers) submit via ChartSwap .
Billing statements only → submit via ChartSwap .
Imaging reports for hospital imaging services interpreted by a Jefferson Radiology radiologist → Contact the hospital.
Images (CDs) — to request images from CT Imaging Partners or Farmington Imaging Centers, please fill out the Attorney and Client Information form below.
Please note: We do not accept drop-off requests at our Outpatient Imaging Clinics.

Questions on Where to Submit Your Request?

Call 860-289-3375 , extension 8276, option 2, to speak with the Jefferson Radiology Revenue Services department when you need to verify where or how to submit imaging requests.
For questions or issues with ChartSwap requests, please email detcustomerservice@optum.com .

Processing and Delivery Timeline

Attorney requests are processed within 30 calendar days.
For records and billing request timelines, please contact ChartSwap. .
Medical imaging CDs and additional items requested will be included in the shipment via FedEx.

"*" indicates required fields

Attorney and Client Information Form

Attorney Full Name*

Law Firm Name

Attorney Email Address*

Attorney Phone Number*

Attorney Fax 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

Before You Submit Your Request

Questions on Where to Submit Your Request?

Processing and Delivery Timeline

Attorney and Client Information Form

Record Details

Need to Book An Appointment?

Our Partners