MedChart - Rutherford Medical Clinic

Organization Information

Welcome to Rutherford Medical Clinic's release of information process. Please complete the following information to submit your request.

Organization Name *

Organization Type *

First Name *

Last Name

Province *

Email *

Phone *

SDM Type *

First Name *

Middle Name

Last Name *

Relationship to client *

Contact Email

SDM Document *

Patient Information

Who are you requesting for? All fields are required.

Patient File Number

Patient First Name *

Patient Last Name *

Patient Date of Birth (YYYY-MM-DD) *

Patient Email

Patient Phone

Not submitting a healthcard number may result in your request taking longer than usual or risking rejection.

Patient Health Card Province

Patient Health Card Number

Please ensure that all information submitted here matches the patient's health card. Providing information that does not match the health card will incur slower processing and the possible rejection of the request.

Information Summary

Please review your submitted information. Ensure all submitted information is shown exactly as it appears on your health card.

Please confirm that all of the above information is correct prior to submitting your request.

Authorization and Documents

Please upload a valid authorization to access these records. It is recommended to include supporting documentation with your request. Please combine all authorization forms and supporting documents in a single PDF.

If you are submitting a request signed by an authorized substitute decision maker (SDM), you will need to upload additional documents supporting the SDM's status. SDM Requirements

I agree to Medchart's terms and conditions and consent for them to use the information provided to retrieve medical records on my behalf.

Payment Information

Date Range
Attention Items

Item Type

Fee

Eletronic Fee: $

SubTotal: $

HST: $

Total: $

Credit Card Online

Payment by cheque:

1) You will receive your printable invoice by email, please download and mail it with a single cheque for the total amount of the request, payable to:

MEDCHART INC.
503 - 460 RICHMOND ST. W.
TORONTO, ON, M5V 1Y1
CANADA

Please DO NOT mail the cheque to the provider, as Medchart manages all payments on their behalf.

2) Press the Submit button below to finalize your record request.

Cancel

Organization Information

Before we begin,

Patient Information

Request Details

Information Summary

Request and Invoice Summary

Total: $

Authorization and Documents

Payment Information

Total: $