Medical Records Request – CommunityMed Family Urgent Care

"*" indicates required fields

Please submit a request for Medical Records by filling out the form below. A member of our team will be sure to get back to you within three business days (Mon – Fri). If you need a copy of our HIPAA form, please mention so in the message box below. One of our staff members will be sure to provide you with one. Please note: Some Record Requests do incur a fee. You will be informed of what this fee is during the request process.

Hidden

Source

Your Name*

First Last

Patient Name (If different from above)

First Last

Patient Date of Birth

Phone*

Email*

What Records are You Requesting?*

Medical Records for a Visit

FMLA Paperwork

Lab Results

How Would You Like Us to Send You the Records?*

Fax

Pick-Up at a Clinic

Mail them

Document Upload

Max. file size: 128 MB.

If you have documents to upload (affidavits, HIPAA Release forms, employer paperwork, etc.) please do so here.

Fax #

Clinic Location

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Message for our Med Records Team (Optional)