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 Fields marked with (*) are mandatory Date Requested *: Requested by *: Requestor's Company*: Requestor's Address: Requestor’s City: Requestor’s State: Requestor’s Zip: Requestor’s Phone*: Requestor’s Email*: Reason for Request*: Items Requested Medical Records Itemized Billing Statement Records of Request Patient Name*: DOB *: Date of Incident (Required for Personal Injury): Date Range *: Upload Signed HIPAA (-) Remove Add More (Please upload only .PDF,.DOCX or .DOC file. Maximum Size: 4MB) Notes Comment
