Records Request Form

Records Request Form

  • MM slash DD slash YYYY
  • Please upload Release of Information Consent or Proof of Identity (birth certificate or driver's license/state ID) for your request to be completed.
    Drop files here or
    Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
    • Crossnore does not release any 3rd Party documents (documents obtained from external agencies during the course of services) or Psychotherapy Notes.