Request for Medical Records
All patient health care information is confidential and protected by State and Federal laws and HIPAA regulations. Medical records can only be released with proper authorization from the patient or the patient's legally authorized representative (unless otherwise authorized by law).
Typical fulfillment time is 5 business days or less plus shipping time if applicable.
PATIENT INFORMATION
First Name
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Last Name
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Date of Birth
MM
/
DD
/
YYYY
Date of Accident
MM
/
DD
/
YYYY
Treating Facility
RECORDS REQUESTED BY
Office
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Contact Name
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Contact Email
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Contact Phone Number
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PREFERRED DELIVERY METHOD
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Shipping, Email or Fax Information
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Additional Notes
Typical Records Include all Progress Notes, Exam Notes and the Patient's Billing Statement. Please specify below if any additional documents are needed.
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