RecordQuest - Request Portal

Welcome! Boice-Willis Clinic, PA has partnered with RecordQuest to make it easy for you to request copies of medical records.

Let's get started! Which type of requester are you?

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Patient

You are the patient requesting your own records or an individual with the legal right to make healthcare decisions on behalf of the patient (e.g. parent, legal guardian, healthcare proxy, etc.). Upon completion, records will be delivered directly to you via a link sent to your email address or texted to your phone.

Third Party

You are a third party (attorney, insurance company, etc.) requesting records for someone else. You will need to supply additional documentation to verify that you're authorized to make this request.

Only copies of medical records may be requested through this site. Please contact the practice directly or use their patient portal for school, FMLA, disability, or other form completion requests.

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I Understand

Location of Records

To which facility would you like to submit your request?

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Boice-Willis Clinic, PA

PO Box 7200, Rocky Mount, NC 27804-0200

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Protecting Your Privacy

Attestation Requirement

On April 22, 2024, OCR issued a Final Rule, entitled HIPAA Privacy Rule to Support Reproductive Health Care Privacy. The Final Rule strengthens the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule by prohibiting the disclosure of protected health information related to lawful reproductive health care in certain circumstances.

This rule provides important safeguards to help prevent your sensitive health information from being shared for investigations related to legal reproductive health care. If someone requests your records for reasons like law enforcement, they must provide information that demonstrates a substantial factual basis that the reproductive health care was not lawful. If someone has asked you for your medical records, understand your rights before passing them along.

A signed attestation may be required for your medical record request. If you are the person ultimately utilizing the medical records, you will be able to electronically sign an attestation as part of this process. If you are NOT the person ultimately utilizing the records, you must obtain a signed HHS OCR Model Attestation from the intended recipient and include it with your request. If you fail to provide a signed attestation, your request may be rejected.

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Please Clarify

Are you the patient? Or, are you a representative with the legal right to make healthcare decisions for the patient?

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Patient

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Patient's Representative

Relationship to the patient?

Please Explain

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Please let us know why you need the records. Your response will help us more accurately copy what you need.

Personal Copy

A copy for my personal records.

Transfer of Care

Transferred to a new healthcare provider.

Referral to Specialist

Referred to a specialist.

Disability Determination

To support a claim for disability benefits.

Insurance

For an insurance application, claim, etc.

Legal Matter

For a legal matter.

Other

Please explain:

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Please help us understand why you are transferring to a new provider.

Moved

Moved out of the service area.

Insurance Changed

Insurance changed and current provider is no longer an option.

Graduated to Adult PCP

Pediatric patient aged-up to an adult primary care provider.

Other

Please explain:

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Patient Information

Please enter your name, date of birth, and last four of social security number. You may include middle initial in the first name field.

Please enter the patient's name, date of birth, and last four of social security number. You may include middle initial in the first name field.

Please enter the patient's name and date of birth. You may include middle initial in the first name field.

Your First NamePatient's First Name

Your Last NamePatient's Last Name

Date of Birth (MM/DD/YYYY)

Last Four of Social Security Number

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Please enter your current address.

Please enter your full name and current address.

Please enter your full name, company name, and company type.

Your Full Name

Company

Address

City

State

Zip

Type of Company

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Please choose any factors applicable to your request. Select all that apply or skip, if none.

Subpoena

Records are being requested under subpoena, discovery request, or court order.

Disability / Govt Benefits

Records are being requested in relation to a claim for SSA disability benefits or other government benefit program.

Workers' Compensation

Records are being requested in relation to a claim for workers' compensation.

Investigation / Assessment

Records are being requested in relation to an investigation by government agency (e.g. DSS, DCF, CPS).

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Your company's identifier to help locate this request when we respond. Please do not use patient's date of birth or social security number.

Description

Value

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What type of information would you like to request from the patient's chart?

Note: You will have the option to restrict by date range on the next screen.

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I will choose from the list below.

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I would rather explain it.

Progress Notes

Radiology / EMG

EKG / Echo / Stress Test

Colo / EGD / Endo

Pathology/OP Report

H&P / Disc Summary

Laboratory Reports

Immunizations

Itemized Bills

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Would you like to limit the information included to a specified date range?

No

Please give me all dates of service.

Yes

I will specify a date range.

Not Sure

I'm not sure. I'd rather explain.

Start Date

End Date

to

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Please enter at least one contact method you would like us to use when communicating with you about this request.

Email Address

Phone Number (Text-Capable)

Primary Contact Method

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Email

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Text

A confirmation message will be sent to your primary method when you press Next.

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How will you provide an attestation? Choose an option below.

Electronic Signature

I will complete and electronically sign an attestation on the next screen.

Upload Signed Attestation

I will upload a completed and signed attestation.

Not Required - Authorization

I will upload a HIPAA-compliant authorization signed by the patient.

Not Required - TPO

This request is strictly for treatment, payment, and operations (TPO) purposes.

Not Required - Court Order

I will upload a court order, signed by a judge, authorizing the release of the records.

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Step 1 - Recipient

Name of person(s) or specific identification of the class of persons to receive the requested PHI.

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Step 2 - Location of Records

Name or other specific identification of the person or class of persons from whom you are requesting the use or disclosure.

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Step 3 - Patient and Request

Description of specific PHI requested, including name(s) of individual(s), if practicable, or a description of the class of individuals, whose protected health information you are requesting.

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Step 4 - Investigation

I attest that the use or disclosure of PHI that I am requesting is not for a purpose prohibited by the HIPAA Privacy Rule at 45 CFR 164.502(a)(5)(iii) because of one of the following:

Is Not Investigation

The purpose of the use or disclosure of protected health information is not to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care or to identify any person for such purposes.

Is Investigation

The purpose of the use or disclosure of protected health information is to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care, or to identify any person for such purposes, but the reproductive health care at issue was not lawful under the circumstances in which it was provided.

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Step 4 - Investigation Cont.

Documentation Required

Please include information that demonstrates a substantial factual basis that the reproductive health care was not lawful.

You will have an opportunity to upload documentation after completing this attestation.

Failure to supply this information may result in the rejection of your request.

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Step 5 - Signature

By entering your name below, you acknowledge that it constitutes a valid electronic signature. This electronic signature holds the same legal weight as your handwritten signature, in accordance with applicable laws and regulations.

Signature of person requesting the PHI

Type Your Name Above

If you are signing as a representative of the person requesting PHI, provide a description of your authority to act for that person.

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Documentation / Authorization

Identity Verification

Please upload any supporting documentation including your request letter and a signed authorization.

Please upload your driver's license or other government ID. You may use the camera on your device to take a photo of it.

Please upload a driver's license or other government ID for both you and the patient You may use the camera on your device to take photos of the IDs. You should also upload any documentation you have authorizing you to request the patient's records.

Upload one file at a time (3 max)
PDF, JPG, and PNG file types accepted
25 MB file size limit
Do not upload password protected files

Upload File

Use Camera

Close File Uploader

Having trouble? Try the Basic Uploader

Drop file here or browsePDF, JPEG, and PNG only

Close Camera

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Do you have any additional information that will help us more accurately and completely respond to this request?

Because you did not upload any supporting documentation, there is a risk that your request will be rejected. Please add any information that might helpful to us in verifying your identity (e.g. driver's license number). There are no refunds for rejected requests.

Because you did not upload any supporting documentation, there is a high risk that your request will be rejected. Please explain the lack of documentation and reason for the validity of this request.

Note

Delivery notifications will be sent via to: . Alternative delivery instructions entered below will not be honored.

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Once your request is fulfilled and ready for delivery, we can send you easy-to-follow instructions for securely downloading your records. This gives you the most control over your information. You will have a copy for printing or forwarding to anyone you choose. You also have the right to request your records be sent directly to a third party.

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Send the records to me

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Send the records somewhere else

You will be notified by email at

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By Email

(Secure Download)

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By Fax

(Less Reliable)

Attention (Name or Dept)

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Your information request is ready to send. After you click the submit button below, your request will be queued for fulfillment.

Please keep in mind that requests are processed on a first come, first serve basis and may take a few days to complete.

Your information request is ready to send. After you click the submit button below, we will create the request in our system and generate an invoice.

You must pay the invoice on the next screen before your request will be processed.

Your information request for is ready to send. Just click submit below and you're done.

Thank you for using the Boice-Willis Clinic, PA Request Portal!

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Submit

Release Authorization

Decline

Accept

Declining will cancel this request. The form will therefore not be completed which could affect your benefits.

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Facility

RQ-ID

Patient Name

Date of Birth

Description Per Qty Fee

Amount Due

TOTAL

PAYMENT

BALANCE

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Submit

Download Acknowledgement

Create New Request

Our Request Portal is currently out of commission. Please try again later.

RecordQuest's Request Portal makes requesting records easy! However, we are unable to find a provider at the address you specified. It should be in the form:

AskForRecords.com/ProviderID

Please contact your healthcare provider to get the proper link with their identifier included.

Thank you!