Request Access Form

Tell us your name *
Enter your email *
Enter your Date of Birth *
Phone No *
ZIP Code
Please consider using this portal to obtain all uploaded records.
Any other concern
I understand that my request will be processed within thirty (30)days. I understand if I checked the “I Agree” box above to review ONLY the information specified to be released. I understand that this request for release of information may be denied or reduced and only portions released. If so, I have the right to request a review of this decision by submitting my request online to the Privacy Office of HopeQure. I understand that on receieving the information Hooequre will hold no responsibility of the information access provided.
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