Dependent Medical RECORD ORDER FORM

Name of Dependent During Treatment

Social

Security

Number

                       Date of Birth

  Last

 

   

 

 

Month 

Day

Year

 

 

  First

 

 

 

  Middle

 

 Name of Military Relative

Social Security # of Veteran

Branch

 

Service #             

Last

 

 

 

 

First

 

 

 

Middle

 

 

  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)

 

Section III

 

 

 

  Requester is the patient named above

  Next of kin of deceased patient

Date of Death       

  Legal Guardian Submit POA

  Others Please Specify

 Relationship         

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 PAGE

Paying by Check? Attach a copy of the check below.

YOU MUST MAIL THE CHECK AS WELL

Did you fax Form

Yes      No

# faxed from

 

Did you mail Form

Yes      No

Date Mailed

 

Did you email  Form

Yes      No

Email Address  Sent by

 

Paid online

Yes      No

Receipt Number

 

Paid Check

Yes      No

Name on Check

 

FAX TO 1 (314) 754-9690
Tel. 703 560 3922

MAIL TO    LYON RESEARCH
                   P.O. BOX  645
                   Dunn Loring, VA   22027-0645

Amount Paid

 

Date Paid

 

 

 


Attach copy of Check HERE
 

Be sure to Mail the Check!!

SIGN THE ORDER FORM