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New Medical Records Request

Patient Medical Record Information

Patient First Name:

Patient Last Name:

Patient Date of Birth:

Requested Information

All medical records will be provided for a flat fee of $50.
NOTE: Billing records are not available. They should not be requested.
NOTE: Radiology images are not available. They should not be requested.
NOTE: Affidavits, Certifications, and Notarizations are not available. They should not be requested.

Designated Third Party Recipient

Type of Recipient:

Third Party Contact Information

Company Name:

Attention:

Address:

Line 2:

City:

State:

Zip:

Phone Number:

Ext.:

Fax Number:

Email:

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