Third-Party Records Request

Third-Party Medical Records Request

CommunityMed Urgent Care — Attorney, Insurance, or Records Company

Requestor Information

Requestor Type *

Company / Firm Name

Contact Name *

Email *

Phone

Fax

Street Address

City

State

Zip

Patient(s)

Add one or more patients. Each patient will generate a separate records request.

Patient #1

First Name *

Last Name *

Date of Birth *

Record Types

Medical Billing Radiology Lab

DOS From

DOS To

Notes