Request Your Medical Records

CommunityMed Urgent Care — Patient Records Request

Patient Information

First Name *

Last Name *

Date of Birth *

Phone

Email or phone is required so we can contact you about your request.

Is this patient under 18? Yes, I am the parent or legal guardian requesting on behalf of a minor

Records Requested

Record Types

Medical Records Billing Records Radiology / Imaging Lab Results

Date of Service (From)

Date of Service (To)

Leave blank to request all available records.

Additional Information

Special Instructions or Notes

Supporting Documents (optional)

Attach a photo of your ID, signed HIPAA authorization, insurance card, or any other supporting document. PDF or image files up to 25 MB each.

Document Type

File