Medical Records Request

Medical Records Request

by paincare

**Please note that a fee will apply for any medical records that are being requested directly to the patient. There is NO fee when the records are released to another physician or hospital. Contact the medical records department to obtain a description of copy fees at (913) 901-8880 option 0.

In order for us to best serve you please follow the steps below when requesting Medical Records:

  1. Have the physician(s) Full Name, address and phone number available in order to complete the form.
  2. Please make sure and mark the correct box of what you need PainCARE to do (this is the second section to be completed on the form).
  3. Completely fill out the information of whom you are requesting your records be sent to or obtained from.
  4. Please mark what part of your records you are requesting.
    Please read and initial the Authorization for Use or Disclosure of Protected Health Information.
  5. Please Sign and Date the form.

Please click on the button below to view the Medical Records Request form:

Download Form

You may print this form off and submit it any of the following ways:

E-mail your completed and signed form to

Fax your completed and signed form to (913) 901-8898.

Send your completed and signed form to 10501 Metcalf Ave. Overland Park, KS 66212

Once your request has been received you will be contacted by our office. You will be notified of any applicable fees and when you will be able to pick up your records.