Patient Request for Medical Expense Report

• Please allow up to 3 business days to process your request.
• Patient Name*
  First Last
• Legal Guardian Name
  If you are the legal guardian for the patient, please enter your name.
  First Last
• Email*
  *Will be used for confirmation of your request. Note: we cannot email HIPAA-related information.
• Patient Date of Birth*
  Month

  Day

  Year
• Date Range of Report*
  From
  Month

  Day

  Year
• To*
  To
  Month

  Day

  Year
• Mailing Address*
  We must mail your records to the address that we have on file. Please verify that address by entering it below.
  Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code
• Signature*
  Signature of patient or guardian requesting this report.
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