Medical Records and Billing Request

Medical Records and Billing Request
Todays Date*
PATIENT INFORMATION:
Name of Patient*

First NameLast Name
Patients DOB*

MonthDayYear
Date
Services Needed:
Dates of Service Needed. If left blank we will send you our ENTIRE chart from the beginning of time for this client.
Medical Records (brief)Medical Records (full)Bill Balance onlyBill Full StatementsAffadavit of Bills and Records
Date Needed by (if any). Please note that in most cases, our turnaround is much quicker than "standard" 15 business days. Please let us know if we are working against a deadline.
Requestor's Name*

First NameLast Name
Name of Firm Requesting Records*
Email of Person Requesting Records*
example@example.com
Direct Phone line to person requesting records*

Area CodePhone Number
Any notes (special circumstances etc)
Please upload a valid request for records on your letterhead here to Satisfy HIPAA requirements (example - HIPAA authorization, letter of representation, records request, etc).

Browse Files

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Please note our CONFIDENTIAL / PRIVATE contact information:

Case Management Phone (512) 402-7588

Case Management Fax (512) 271-6491

Case Management Email: casemanagement@paincaretx.com
Signature of Person Requesting Records
PLEASE NOTE THAT UPON SUBMISSION/SIGNATURE, YOU WILL RECEIVE AN EMAIL CONFIRMING THE REQUEST. IF YOU DO NOT RECEIVE AN EMAIL THEN IT DID NOT GO THROUGH AND YOU MUST RE-SEND IT.

PLEASE CLICK BELOW TO SUBMIT.
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