Medical Office Only: Request Records

Medical Office Only: Request Records
Directions:

Complete this form if your medical office needs to review a patient’s records for the care s/he received at Burbank Urgent Care. Again, this form should only be completed by a medical office (e.g., provider, health facility).

Burbank Urgent Care will email information back to the medical office typically on the same day if the request is submitted by 3 PM.

Here is what Burbank Urgent Care will include in the email: 1) The provider’s transcription note and 2) Any imaging report results (if applicable).

Be sure to look for an email which contains @burbankurgentcare.com
What is the name of your medical office / health facility?*
What is the address of the medical office / health facility?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What's the office telephone number?*
Please enter a valid phone number.
What is the name of the provider requesting the records?*

First NameLast Name
What is the patient's name?*

First NameLast Name
What's the patient's date of birth?*

MonthDayYear
Date
What's your email?*
example@example.com
Confirm your email.*
example@example.com
Approximate date the patient received care with Burbank Urgent Care?*

MonthDayYear
Date
Is the patient a minor?*
If yes, what is the name of the parent or guardian?

First NameLast Name
If yes, what is the relationship?
I testify that I work in this stated medical office.
Your Signature

First NameLast Name
Your Signature

Clear
Should be Empty: