Patient Request for Medical Expense Report Please allow up to 3 business days to process your request. Patient Name* First Last Legal Guardian NameIf you are the legal guardian for the patient, please enter your name. First Last Email**Will be used for confirmation of your request. Note: we cannot email HIPAA-related information. Patient Date of Birth* Month Day Year Date Range of Report*From Month Day Year To*To Month Day Year Mailing Address*We must mail your records to the address that we have on file. Please verify that address by entering it below. Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Signature*Signature of patient or guardian requesting this report.