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New Medical Records Request

Facility / Facilities

Patient Information

Please select the visits/admissions you would like released:
Please select the type of information you would like released:
Medical Records
Itemized Billing
Radiology Images (The Radiology Department will follow up if any charges or additional information is required.)

Purpose of Request

Please enter your reason for requesting records.

Your Information

Delivery Information

Normal processing time is 5 business days from time of receipt. Please contact us if you have any questions.

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