RECORDS/PAPERWORK REQUEST FORM
If your answer to this question is yes, please be sure to describe the your concerns in the Chief Complaint. BILLING issues include Patient Unpaid Balances, Superbills, and No-Show Fees.
Please describe any important details/background information you feel we should know regarding your paperwork request such as, deadlines, a designated point of contact, phone numbers, etc. If you are in need of medication refills, please fill out designated Refill Request Form.
Note that this form must be completed before in PHI can be forwarded to the intended recipient.
If answered yes, please input the payment date.
Paperwork Fee Schedule
*All paperwork request submitted before 4:30pm will be reviewed within 1-2 business days of the day that it is received. Please allow 7-10 business days for your request to be processed after review.*
Please be advised that our office does not provide patients with a personal copy of their medical records regarding Disability, FMLA, CPS cases and legal matters. If you feel that you are in need of a personal copy of your records, please contact the Medical Records Department via phone, and someone will be available to help process your appeal.