Third-Party Records Request

Third-Party Medical Records Request

Citra Urgent Care — Attorney, Insurance, or Records Company

Requestor Information

Requestor Type *

Company / Firm Name

Contact Name *

Email *

Phone

Fax

Street Address

City

State

Zip

Patient(s)

Add one or more patients. Each patient will generate a separate records request.

Patient #1

First Name *

Last Name *

Date of Birth *

Record Types

Medical Billing Radiology Lab

DOS From

DOS To

Notes

Supporting Documents (optional)

Attach signed HIPAA authorization, attorney letter, subpoena, affidavit, or any other supporting document. PDF or image files up to 25 MB each. Documents attach to all patient requests in this submission.

Document Type

File