Medical records request

Requester Information

Today's Date

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Name of Firm *

Requestor's Name *

Address

Address Line 1

City

State / Province / Region

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Phone Number

Email Address *

Request Type and Fees

Case Type *

Personal Injury
Motor Vehicle
Workers Comp
Other

Records being requested (check ALL that apply): *

*Medical records exceeding ten pages are charged at $1.50 per additional page

Patient information

Patient demographics including name, DOB, hospital or location name with city and state are required for the fulfillment of any request. If this information is not provided, request will be rejected.

Patient Name (Last, First) *

First

Last

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Name of HOSPITAL where patient was seen: *

Date of birth: *

City, State where patient was seen: *

Date of injury or first service: *

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Date range of request *

All time
Specific date range

From *

To *

Additional Information

Attach patient authorization for release of records *

Additional Information pertinent to this request (if any): *

Requester Information

Request Type and Fees

Patient information

Additional Information

Contact

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