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    Company Name: *
    Your Name: *

    Please upload your request including the HIPAA Consent, if required.

    * Required Field

    Medical Records

    Please fill out the form to submit your medical records request. Alternatively, you may also submit your medical records request through email or fax.

    Fax: (646)351-0690

    We will be in contact within 5 business days after we confirm patient information. If necessary, we will email you with next steps in terms of financial payment. Please make sure that your name, phone number, and email above are filled in accurately so that we can contact you.