Incident Report Request Form
Obtain the Incident Report Request Form (PDF) and complete. Form may be submitted n person, via fax or email. If the request is submitted in person, please bring valid picture identification. If the request is submitted vial mail, please include a self-address stamped envelope.
Request & Authorization for Disclosure of Health Information Form for Medical/Patient Care Report
Obtain and fill out the Request and Authorization for Disclosure of Health Information Form (PDF). Please note we require the HIPAA form, completed, signed and NOTARIZED by the patient. As we need to have the original on file, the original document must be mailed or can be picked up at our office (with identification). Once received, report will be mailed and cover letter will include the cost for the report. We are unable to email or fax patient care reports.