Request For Records

What records would you like sent back to you? Please include exact date(s), full name(s) of patient if applicable, location of incident(Required)

Relationship to the Claim(Required)

Are you the homeowner, patient, patient or homeowner attorney, patient or homeowner insurance carrier, next of kin

Cost of copies

Please inform me of the cost of providing paper copies of the following records (Include as much details as possible such as full names, dates, descriptions. etc...)

Please give a brief description of the incident(Required)

If your request is too broad or does not reasonably describe the records, we will contact you via email so that you may clarify your request, and when appropriate, indicate the manner in which records

If my request must be modified, I would prefer to be contacted by phone at this number

Name

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Denied Requests

If for any reason any portion of my request is denied, please inform me of the reason in writing and provide the name, address and email of the person or body to whom an appeal should be directed