Records Request Amount (required) $ Contact Information 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)Patient Care Report Billing History Report Fire Report Inspection Report Fire Investigation Report UAS Data 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)Stripe Payment (Online) Pay at Front Office
