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New Medical Records Request

Patient Medical Record Information

Patient First Name:

Patient Last Name:

Other Patient Names (Optional):

Patient Date of Birth:

Requested Information

NOTE: Physical Therapy records are included in Medical Records.

Medical Records

Itemized Billing Records

Radiology/Imaging CDs

Include visits from today or yesterday? (May delay processing by 5 days)

Requestor Contact Information

Relationship to Patient:

Name:

Cell Phone Number:

Retype Cell Phone Number:

I cannot receive text messages at this phone number. (You will be contacted by email, which may add an additional 3 days of processing time.)

Delivery Method for Imaging CD(s)

Please select a delivery method for your imaging (X-Ray, MRI) CDs. For mailing, please allow an average of 7 additional business days.

CD Delivery Method:

Please note: The CDs you receive will contain images only. Please allow 5-7 business days for your CD to be prepared. For mailing, allow an additional average of 7 business days for delivery. If you requested written medical and/or billing records, they will be delivered online to you within 5-7 business days of receipt of your request (excluding weekends/holidays).

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