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Third Party Medical Record Request

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As one of Canada’s largest medical record repositories, RSRS fulfills requests for certified record copies from law firms, insurance companies, government agencies and other authorized third party requestors. To initiate a record request, please read the following and then complete the form below to proceed. One of our representatives will contact you as soon as possible.

Instructions

You must be authorized to request the record of another person. Typically, this requires a Letter of Authorization (or Release of Information Form) signed by the patient or legal guardian. A signed Power of Attorney, (or equivalent), should be provided where a patient signature is not available. Required document(s) should be uploaded along with this request by attaching below. (See “Attach Release of Information Form” section.)
Patients 16 years of age or older must sign for the release of their own records.
You will receive a certified COPY of the patient record. The original record is the property of the physician.
Each certified copy of a medical record is delivered as a digitally scanned file by secure download (unless other arrangements are made). The file will be fully text searchable for ease of reference.
A non-refundable Search Fee of $50.00 + sales tax is payable immediately with this request. Searches are not initiated without receipt of this fee. If you wish to pay by credit card, please call 1-888-563-3732 Ext. 641. (If you wish to mail in a cheque, please mail in a printed copy of the form along with the cheque. Make cheques payable to “RSRS Inc.” and send to RSRS Inc. – Third Party Requests, 111 St. Regis Cres. S., Toronto, ON M3J 1Y6.)
A Copying & Delivery Fee is charged separately. RSRS will send you an invoice for copying & delivery once the record has been located and assessed.
Rush Requests should be made by contacting us at 1-888-563-3732 Ext. 641. Additional charges may apply.

Please proceed to fill in the information below, attach a digital copy of the “Release of Information” form, (if available), and click “Order Patient Record” to go to the Printable Order Form Page. (If you are looking for your own medical record or the medical record of a family member, click here.)

Patient Information

I am requesting a medical record from the practice of:

Doctor's First Name*
Doctor's Last Name*
Doctor's City*
Doctor's Province*
Patient First Name*
Patient Last Name*
Patient Date of Birth*
MM
DD
YYYY
Date patient was last seen by doctor, (if known)
MM
DD
YYYY
or choose an estimated date range when patient was last seen by doctor (choose only one)
- Within the last 12 months
- 2-3 years ago
- 4+ years ago
- Do not know
Your File Reference or Claim Number (optional)
Confirm Authorization to Obtain Medical Record
- Click here to confirm that you have been authorized to obtain the medical record pertaining to the patient for whom you are submitting this request.
Attach Release of Information

If you are not the patient or the parent/legal guardian of a (<16 year-old) patient, you must provide supporting documentation in full (e.g., a copy of a Release of Information form signed by the patient or a copy of a Power of Attorney including type of POA).
Option One: to attach a digital image ( jpg, jpeg, png, gif) of a Release of Information signed by the patient or patient's guardian/representative click "Choose File" to find your file and then click "Upload".
Option Two: to attach a PDF (Adobe Acrobat Reader) copy of a Release of Information signed by the patient or patient's guardian/representative click "Choose File" to find your file and then click "Upload".
If you have problems uploading your file, send your digital copy of the patient's Release of Information to thirdpartyrequest@rsrs.com. If you cannot create a digital version of your Release of Information form, please fax it to 1-877-398-5932.
Requesting Organization
Organization Name*
Street Address*
City*
Prov.*
Postal*
Contact First Name*
Contact Last Name*
Email address*
Phone Number (include ext. #)*
Fax Number*
Payment for Search Fee

When you click the "Order Patient Record" button, you will be taken to an order form. Please print the order form and include it with your cheque for the $50.00 non-refundable search fee +sales tax.
Special Requests
Type any additional information or special requests in the field below. Additional charges apply for rush requests. (Please include date required for rush requests).
Comments
By clicking "Order Patient Record" I certify that I have read, and understand the information above regarding record requests and payment obligations.

Instructions

Patient Information

Confirm Authorization to Obtain Medical Record

Attach Release of Information

Requesting Organization

Special Requests