Records Requests

Please use the form below to submit a request for records.  We will attempt to have your medical records to you within 10 business days, unless there is an urgent matter that requires them sooner.

Please Indicate the Type of Records You are Seeking *

Annual Physical Exam Records

Applicant/Post-Offer Medical Evaluation Records

Other

IF SEEKING PSYCHOLOGICAL EVALUATION RESULTS, PLEASE CONTACT YOUR DEPARTMENT. DO NOT CONTACT PUBLIC SAFETY MEDICAL.

Please Indicate "Other" Records You are Seeking *

Person Whose Records are Needed

First Name *

Last Name *

Date Of Birth *

Employer/Dept. *

Phone Number *

Email Address *

Please list the records you are requesting *

Person Requesting Release of Records (if different from above)

Name of Person Requesting Records

Affiliation to Person Above

Contact Phone Number

Contact Email

Getting your records

How would you like to receive your records? * EmailFaxOther

Delivery Email *

Delivery Fax *

Provide "other" means of how you would like to obtain your records. *

Attention to *

Would You Like an E-mailed Confirmation of this Request? *

Yes

No

Please Provide Any Other Information We Need to Know.

If this Form was Completed by a PSM Staff Member, Please Enter Your E-mail.

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Note: Records will be provided within 10 business days unless special arrangements are made. Customary fees may apply when necessary.