Request Your Medical Record

First Name: *

Last Name: *

Address: *

City: *

State: *
Two (2) letter abbreviations only.

ZIP: *
Five (5) digits only.

Email: *

Phone: *
Please provide the best number to reach you.

Fax:
Please provide if available

Date of Birth: *
Please use MM/DD/YYYY format.

Social Security Number: Last Four Digits: *

Organization

Which hospital are you requesting records from? *

Date(s) of Visit(s): *

Select the information you would like us to share. *

What type of radiology records are you requesting?

If you selected "other" above, please tell us what information you were needing instead.

All requests will be processed and delivered as quickly as our resources allow. Times listed below are estimates only.

Delivery Options: *

Note: the time to process and release is provided for each option.

If sending by USPS MAIL please select format: