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Medical Records Release Forms

Request My Records:

Do you need to obtain a copy of your medical records from our office? Do you need our office to request your medical records from another doctor’s office?

Click here to print a copy of our Medical Records Release form. (Printable Version)

Click here to fill out the Medical Records Release form. (Fillable Version)

All medical records releases require a signature. Once you complete and print the form, you can mail, fax or bring it to our office. Our address and fax number are listed on the form. If you will be picking up your records, you can scan and email the form to our office at

Note: If you decide to fill out these forms and then email them back to us, please be aware that you have a choice to either send documents via email (which is not protected), or you can print, complete, and return the forms on-site to our practice.

Contact Information

Northland Women's Health Care, PC

5844 NW Barry Road, Suuite 310
Kansas City, Missouri 64154

Phone: 816-741-9122
Fax: 816-741-9665

Payment Options


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