Request for Patient Medical Records and Billing Information
$95.00
Patient First Name
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Patient Last Name
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Patient Date of Birth
Please choose a date
Email where records should be sent
Enter your text
Phone Number
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Injury Date and Details (if applicable)
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Product Details
To better serve you, we’ve created this secure form to request your medical records and billing information.
• A processing fee is required to cover administrative costs associated with fulfilling your request.
• Once your payment is received, our team will process your request promptly.
• Records, including a radiology report, will be emailed to the email address in the form
Please complete the form above, including your name, contact information, Patient name, and Date of birth. If there is a date of injury please provide that. Please note this is the only way to request records.
Thank you for choosing Your Health In Motion!
Request for Patient Medical Records and Billing Information
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