Team Rehab - Records Request

Law Firm or Network (required)

Email To Send Records To (required)

Patient First Name (required)

Patient Last Name (required)

Patient Birthdate (required)

Date Span (required)

Start Date

End Date

State (required)

Do Records Need To Be Certified? (required)

Yes

If Yes, Does Certification Need To Be Notarized? (required)

Yes

Please select the documents you are requesting (required)

Itemized Ledger

Treatment Notes

Both Itemized Ledger & Treatment Notes

Full Medical Records (Includes: CMS 1500 forms, intake forms, treatment notes, lien and itemized bill)

Other (Please provide specifics in the "Any other notes" below)

We require a HIPAA compliant authorization with every request signed and dated within one year of today's date. For multiple files, press the ctrl key while selecting. (required)

Any other notes regarding this request: