Personal Records Request

Personal Records Request

for Palmetto Ear, Nose and Throat, P.A.
Please enter your information. Our staff will review your submission and contact you at the email address you provide below to proceed.
Are You the Individual Who's Records You Are Requesting?*

YesNo
I am the Patient's*

Mother/ FatherAttorneyLegal GuardianHealthcare ProviderOther
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Your Email Address*
In order to verify your identity, you'll need to submit a copy of your government issued ID. How would you like to do that? NOTE: you may need to turn your phone sideways to get a good picture*

Upload a fileTake a photo
Upload a file*

Cancelof
Take a photo*
Please enter notes for the review team here
Should be Empty: