Records Request

First Name (required)

Last Name (required)

Email Address (required)

Phone Number (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Type of Record (There is a $30 fee per hour for records requests, unless it’s an individual requesting their own records, then it is waived.) (required)

Requested Document (Please provide the name of patient, incident number, billing number, date of service, or other description of what records you are requesting) (required)

Payment Method (required)

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