Request Patient Records

To request Records and Billing information, please fill out the below fields. Fields with an asterisk (*) are mandatory.

Request Patient Records

To request records or billing information.

Hidden

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

Select the type of record you are requesting(Required)

You may select more than one record type.

Complete Care Integrative Physical Medicine Records

Complete Care Centers for Imaging Records

Complete Care Interventional Associates Records

Complete Care Billing

Requestor relation to the patient

Office Name(Required)

Requestor Name(Required)

First Last

Requestor Email(Required)

Patient Name(Required)

First Last

Patient Date of Birth(Required)

Accident Date(Required)

HIPAA File Upload

File type must be PDF

Max. file size: 2 GB.

Request Notes