On-Line Ordering - Chart Access


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Submit your order On-line

To place your order on-line please complete appropriate fields in the form below and submit using your Web Browser. Please note that although this form does provide strong encryption and security, we strongly recommend that you print and save this information for you records. For questions please contact our Customer Service Department at 800-821-9546.

User Identification:

Please Note: First time users may enter “New User” for their User Name and Password. New applicants will receive their own log-in information within 48 hours.

Click Here to request a User ID

User ID: (Required)	Password: (Required)

Senders E-mail: (Required)	E-Mail Verification (Required)


	Records Pertain To:

Patient:	Social Security Number:

Date of Birth:	Policy Number:

Maiden Name:	a/k/a:


	Records Locations 1:

Physicians Name:		Facility:

Telephone:		Address:

City:		State:

Zip Code:		Date of Treatment:

	Last Five Years		See Additional Information


	Records Locations 2:

Physicians Name:		Facility:

Telephone:		Address:

City:		State:

Zip Code:		Date of Treatment:

	Last Five Years		See Additional Information


	Records Locations 3:

Physicians Name:		Facility:

Telephone:		Address:

City:		State:

Zip Code:		Date of Treatment:

	Last Five Years		See Additional Information


	Select and Attach Authorization Image File ( 500 KB Max )


	PLEASE ENTER ANY ADDITIONAL INFORMATION HERE

Senders Initials


	(Required)




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