Attorney Records Request Form

Please provide the details below to complete your records request.

Attorney's Name *

Law Firm *

Email Address * Registration and records notification will be sent here

Phone Number *

Ambulance Service Provider *

Patient Account Number Typically found on the top right of your statement

Patient Identity

Patient Name *

Date of Birth *

Date of Service *

Call Number (911 INCIDENT NUMBER - LOCATED ON THE TOP RIGHT CORNER OF THE PATIENT BILLING STATEMENT) *

Please do not submit your application without the call number. You will need it later to access your records.

Medical Request (PDF) *

Only PDF files are accepted for medical requests. Multiple files allowed.