ELECTRONIC MEDICAL RECORDS REQUEST
STEP 1 - PATIENT DATA
Patient First Name:
Patient Last Name:
Patient Date of Birth:
Patient Date of Injury:
NOTE: In order to use this system, you must successfully enter the patient's FIRST NAME, LAST NAME, SOCIAL SECURITY NUMBER, DATE OF BIRTH, and DATE OF INJURY.
You will be given three (3) opportunities to submit this information correctly, afterwhich your session will be locked.
TO PROCESS THE REQUEST, ALL FIVE (5) FIELDS MUST BE ENTERED, AND THE FIELDS MUST CORRESPOND TO A ELECTRONIC MEDICAL RECORD / PATIENT VISIT IN OUR SYSTEM.
If you have any questions about this process, or would like to submit a manual request, please call us at 404-761-4040 or email us at
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