Request records from:

Endeavor Health

Select facility to request records from below.

Before you begin:

You will be requesting records from Endeavor Health.
Have photo ID ready to take picture or upload.
Have 10 minutes to complete request.

Is this a request for your records?

Yes (They are mine)

No (Not my records)

Enter PATIENT information.

First Name

Middle

Last Name

Birth Date

Phone #

Check this box if patient’s legal name has changed since you last visited this facility.

Enter other names used below

Enter patient US mailing address.

Mailing address

Suite or Apartment #

Zip

City

State

Why are you reqesting these records?

Time frame of records to request.

If you are unsure about the exact treatment dates, please specify a wider range. We will only send records for the treatment dates that fall within the range provided.

Enter date range

Start Date

End Date

What part of the medical record do you want?

Include sensitive information?

To whom should we release records to?

Me the Patient

A Third Party (e.g. Attorney or Insurance)

A family member or caregiver

Physician's office

How should the records be sent?

PDF file via secure internet portal

Paper via US Mail

Please confirm information you entered below is correct. To make changes click appropriate edit button or navigate back (use back button).

**** scroll down and confirm ****

Any additional information to help process this request.

This authorization request will expire on:

90 days after signature date

One year after signature date

Specific date

If there is no expiration date indicated, this authorization will automatically expire one year from the date signed if no prior notice for revocation is received.

Enter your contact information.

✅❌ Email

✅❌ Confirm Email

A encrypted copy of the completed authorization will be securely emailed to you.

Phone #

Verify identity.

Hold your ID up to camera

Upload your ID (jpg,pdf or tiff)

Sign.

Print full name

By checking the box, You, the patient, agree to use an electronic signature ("e-signature") regarding your request for records; You agree that your e-signature has the same legal validity and enforceability as a manually executed signature to the fullest extent permitted by state and federal law; You understand and agree that is storing your e-signature for record keeping and security purposes; and You also represent and agree you are at least 18 years old and/or of lawful age to sign these documents. Signing below will have the same effect as checking this box and that You understood and agree to the above terms. If you do not agree, you may request a paper copy to sign from erequest@mrview.com.

⇓⇓ Draw signature in box below ⇓⇓

** signed on 08/22/2025 **

Done, click submit to complete. You will receive a email confirmation.

Success! Request Received.

You should receive an email shortly confirming your request.

Enter YOUR information. (Requestor not patient)

Full Name / Company

Attention:

Mailing address

Suite

Zip

City

State

Fax # (optional)

✅❌ Email (optional)

✅❌ Confirm Email

Are you requesting a deceased patient’s record?

Yes

Enter YOUR (not patient) information.

Your FULL Name

Your relationship to patient.

Parent of patient

Caregiver / family member of patient

Legal Guardian of patient

Spouse of patient

Please upload legal documents supporting your relationship to patient. (pdf,tif,png or jpeg)

If you are a parent listed on your minor child’s record you can skip this step and click "next"

Which Northwest Community sub facility to request records from?

Northwest Community Hospital \ Day Surgery

Northwest Community Medical Group.

Both facilities

For mobile device scan QR code

Release of Information services provided by:

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