Instructions and Charges: Complete the following form and hit submit ** You will receive an email once the following has been received. Any missing information may result in a delay. A separate form is required for each request. NO REQUESTS WILL BE HANDLED/ADDRESSED BY PHONE! Requestor’s Information Fields marked with (*) are mandatory Date Requested *: Requested by *: Requestor's Company*: Requestor's Address: Requestor’s City: Requestor’s State: Requestor’s Zip: Requestor’s Phone*: Requestor’s Email*: Reason for Request*: Items Requested Medical Records Itemized Billing Statement Records of Request Patient Name*: DOB *: Date of Incident (Required for Personal Injury): Date Range *: Upload Signed HIPAA (-) Remove Add More (Please upload only .PDF,.DOCX or .DOC file. Maximum Size: 4MB) Notes Comment **If requesting printed records or CD copies and/or Imaging on CD please fill in credit card information OR print request details above and mail with credit card information or check to: NewportCare Medical Group 441 Old Newport Blvd Newport Beach, CA 92663 Click here to pay through Credit Card Credit Card Information Name on Card *: Email *: Amount *: Invoice Number: Credit Card Number *: CVV *: Exp Date (mmyy) *: Zip: Electronic Copy: Courtesy, no charge. Paper Copy: $25 Flat Fee and .25 per page exceeding 30 pages CD request (required for imaging): $10 (All records placed on CD upon request) www.newportcare.org
