Attorney Records Request Form

Attorney's Name *

Law Firm *

Email * (This is where the records will be sent)

Attorney's Phone Number *

Ambulance Service Provider *

Patient Account Number (Assigned by FPSC) This is the billing/account number used by our office – not the patient's phone number

Patient Name *

Patient Date of Birth *

Date of Service *

Call Number (911 Incident Number) - Not a phone number*

Upload the Medical Request *