We've pre-filled what's on file. Please confirm everything is current.
Fields marked HubSpot are pre-populated from your record.
Step 2 of 4
Who receives these records?
Select who we're releasing your information to.
Recipient type
📷 Photo ID required at time of release.
Step 3 of 4
Records & purpose
Tell us what you need and why.
Purpose for this request
Scope
LSC Records OnlyCare administered by Lazar Spinal Care
Include Prior RecordsAlso includes records submitted to LSC
Specific records requested
Chart NotesPer-page cost based on number of pages
Digital X-rays on CD$75.00 fee — includes imaging disc
OtherSpecify below
📦
Need records shipped?
Additional $5.00 postage fee.
Step 4 of 4
Review & sign
By signing, you authorize Lazar Spinal Care, P.C. to release your records as specified.
Authorization valid for
This request onlyOne-time release for records listed above
One year from signingCovers all care records on or prior to date below
I understand that
My right to receive healthcare from LSC is not conditioned on this authorization.
I may cancel this authorization at any time by submitting a written request.
There is a charge for release of records; payment is required prior to release.
Medical records can be faxed to another facility only in cases of medical emergency.
Processing requires a minimum of 48 hours.
Patient signature (required)
Sign here with your finger or mouse
Draw your signature above
Representative signature (if not the patient)
Representative signature (leave blank if you are the patient)
Leave blank if you are the patient
⚠️Please provide your patient signature before submitting.
✓
Authorization received
Your request has been submitted securely. You'll receive an email when your records are ready to download from the portal — typically within 48 hours.
Questions? Call (734) 274-5107
🔐
Secure Records Portal
Enter the 6-digit access code from your email to view and download your records.
Demo: enter any 6 digits
Secure Records Portal
Jane Smith
DOB: April 15, 1982 · Lazar Spinal Care
🔒 Encrypted
ℹ️
Records are available for download for 30 days from the date of release. After that, please submit a new authorization request. Files are encrypted at rest and in transit.
