eTrueNorth - RocketFuel Data Services

To request your protected health information, please fill out the form below.

Patient Information

First Name *

Last Name *

Date of Birth *

Gender *

M F

Address *

City *

State *

Zip Code *

Records Request Information

Description of records requested *

0/1000

Approximate date of service

Location of service

Format requested *

Secure Email Paper Copy

Requestor Information

Relationship to patient *

Self Parent/Legal Guardian Personal Representative Legal Representative

Photo of government-issued ID (state-issued driver license, state-issued non-driver identification, passport, or military ID)* PDF, JPG, or PNG, maximum 1MB

Signature

By signing below, and pursuant to the Health Insurance Portability and Accountability Act (HIPAA), specifically 45 CFR § 164.524, I hereby exercise my right to obtain a copy of my protected health information (PHI) contained in a designated record set. I understand that this request covers all medical and billing records maintained by RocketFuel Data Services, LLC on behalf of E3HealthSolutions, LLC (d/b/a eTrueNorth), including records created by or received from other providers. I request that this information be provided in the form and format specified in this document, provided it is readily producible in such manner. I understand that a fee may be charged for labor, supplies, and postage related to this request, as permitted by federal law.

Signature *