Requesting for your Medical Record is quick and easy with RASCI's secure online HIPAA Compliant system. 

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1. Just fill out the areas marked from Section 1 to 7;

2. When complete, please use your mouse, stylus, or finger to sign your name for your e-Signature;

3. At the bottom of the Form, click on the SUBMIT button.  If you missed some fields, it will be highlighted in RED;

4. You will be directed to a SUCCESS Page if your request was sent;

5. You will receive a message from RASCI on the status of your Medical Record Request

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          * NOTE: If you are unable to use our online Request & Authorization form below, please click on our FORM, print and fax it                 directly to the toll free number shown on our form.