Fresno Medical Records

Request a Copy of Your Medical Records

If you are a current or former patient of Dr. Hedi’s Fresno practice and would like a copy of your medical records, please complete the secure request form below. (Note: patient records older than 2020 may be limited.)

To protect your privacy, we may contact you to verify your identity or clarify your request before releasing your records.

Please allow up to 15 days for your request to be processed.

Patient First Name

Patient Last Name

Date of Birth

Phone Number

Country Phone Number

Email Address

Current Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date

Signature

Authorization

By signing below, I confirm that I am the patient named above, or the patient's legally authorized representative, and I am requesting access to the medical records specified in this form. I understand that Dr. Hedi's office may contact me to verify my identity or obtain additional information necessary to process my request.

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Fresno Medical Records

Request a Copy of Your Medical Records

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