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Record / Billing Request Form

Instructions and Charges: Complete the following form and hit submit

**You will receive an email once the following has been received. Any missing information may result in a delay. A separate form is required for each request. NO REQUESTS WILL BE HANDLED/ADDRESSED BY PHONE!

Requestor’s Information

Items Requested

Records of Request

Notes

**If requesting printed records or CD copies and/or Imaging on CD please fill in credit card information OR print request details above and mail with credit card information or check to:

NewportCare Medical Group
3300 W Coast Hwy, Suite A
Newport Beach, CA 92663

Credit Card Information:

 

Paper Copy: $25 Flat Fee and .25 per page exceeding 30 pages
CD request (required for imaging): $10 (All records placed on CD upon request)

PI Team
NewportCare Medical Group
Tel: 949-491-9991 (Option 4 Personal Injury)
Records@newportcare.org
www.newportcare.org

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