I want a copy of my medical records for myself:

If you want a copy of your medical records from HealthNet, please fill out this form. Please print and complete form with a signature before returning. Once you have completed this form, please send it back to HealthNet by:

Hakha holh a tial mi form caah hi ka hi hmeh.

I need my old doctor to send my medical records to HealthNet:

Please fill out this form to give HealthNet permission to get your medical records from your old doctor. Please print and complete form with a signature before returning. Once you have completed this form, please send it back to HealthNet by:

If your old doctor sends you your medical records, please bring them with you to your scheduled visit.

Hakha holh a tial mi form caah hi ka hi hmeh.

I need to get my medical records from HealthNet to give to another provider, attorney, or other group:

If you need to get your medical records from HealthNet to give to another provider, attorney, or other group, please fill out this form. Please print and complete form with a signature before returning. Once you have completed this form, please send it back to HealthNet by: