Medical Records Request - Next Level Urgent Care

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Medical Records Request

Please complete the form and we will return your paperwork within 3-5 business days.

Name of Patient *

First

Last

Date of Birth (MM/DD/YYYY) *

Person or Company Requesting Medical Records *

Email (Person Requesting) *

Phone (Person Requesting) *

Please upload the completed medical records release form. *

Click or drag a file to this area to upload.

Please choose all that apply:

Medical Records - $25.00
Radiology Records - $25.00
Notary Services/Affidavits for Medical Records and/or Radiology Records - $15.00
Billing Records - $25.00
Notary Services/Affidavits for Billing Records - $15.00
FMLA - $25.00

Total

$0.00

Stripe Credit Card *

Card

Name on Card

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