Medical Records Request - Youth Extensions, Inc

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Consumer Name*

Consumer Date of Birth*

Requestor Information

Name of Person Requesting Records*

Telephone Number*

Fax Number

Email Address*

Records Requested

Please select the records you are requesting.

Clinical Assessment
Service Plan
Other:

Other:

Authorization for Release of Information A signed Release of Information (ROI) is required in order to process this request. Please upload the signed ROI below.

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Max. file size: 512 MB.

Additional Notes (Optional)