Dependent Medical RECORD ORDER FORM
Name of Dependent During Treatment
Date of Birth
Name of Military Relative
Social Security # of Veteran
For outpatient Health Records please answer the following.
Name and location of Last treatment.
Date of last treatment.
For inpatient Medical Records please answer the following.
Name and Location of hospitalizing facility ty.
Year of Hospitalization
Other Documents Needed
Purpose of Documents (Optional)
Requester is the patient named above
Next of kin of deceased patient
Date of Death
Legal Guardian Submit POA
Others Please Specify
To the National Personnel Records Center (NPRC) please allow the Lyon Research staff to act as my representative for the purpose of obtaining any and all of my records. To any other government agency with information concerning the medical records of the above named patient. Please allow the bearer of this form, to be filled in by the research company, to act as my representative for the purpose of obtaining any and all of my records. I allow the (NPRC) or any other Government Agency with information concerning my records to convey in person, by voice, fax, email of postal mail the follwing: all of my records; part of my records, including original discharge; or any information that my be used to obtain my record to my representative. I am aware that fax and emails are not secure transmissions and that there is a chance that others may be able to view my records during transmission.I declare ( or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the information on this SECTION III is true and correct.
PRINT NAME ABOVE SIGN & DATE ABOVE
Street address City State Zip
Day Phone Night Phone Email
USE THIS PAGE AS THE COVER SHEET
BE SURE TO SIGN THE FIRST PAGEPaying by Check? Attach a copy of the check below. YOU MUST MAIL THE CHECK AS WELL
Did you fax Form
# faxed from
Did you mail Form
Did you email Form
Email Address Sent by
Name on Check
Priority Hospitalization file $169.00
Priority Outpatient File $169.00 OTHER______________________________________
FAX TO 1 (314) 754-9690Tel. 703 560 3922
MAIL TO LYON RESEARCH P.O. BOX 645 Dunn Loring, VA 22027-0645
Attach copy of Check HERE
Be sure to Mail the Check!!
SIGN THE ORDER FORM