Medical Documentation Request | Positive Innovations

First name

Last name

Email

Phone

DOB

Month

Day

Year

Documents Being Requested

Requested By

Please specify if lawyer or other was selected above.

Purpose

Other, please specify and include Name/Title, Phone Number, Address, and Email

How would you like the medical documents delivered?

Electronic Rushed Delivery (w/i 7 business days)$25

Electronic Expedited Delivery (w/i 3 business days)$50

*Please note that it can take up to 30 days to process records. If you need the records before the 30 days, please ensure that you have selected "Rushed Delivery" or "Expedited Delivery".

File upload

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Today's Date

Month

Day

Year