Patient Medical Records Request

Medical Records Request

You can now request patient medical records online! Simply, fill out the proper form and one of our friendly staff members will contact you during our normal business hours, Monday through Friday from 7:30AM-5PM, to fill your request.

*Required
Your e-mail address:
Patient Information:
*First Name: *Last Name:
*Date of Birth: (ex:00/00/1900)
*Daytime Phone #: (EX: 239-000-0000) Evening Phone #: (ex: 239-000-0000)

Requested Exam Information:
Location:
Date of Service: (ex: 00/00/1900)
Exam(s) Requested:

Films/Medical Report needed by:

Requested Materials: (select all that apply)

CD ($35.00 each) Films ($8/sheet) Report ($0.25/sheet)

Records go to:
Patient
Physician
Physician's Address:

Requestor's Name:
Requestor's Contact Number:

Please click here to print the HIPAA required medical release form. Fax the completed form to FRC's Medical Records Department at 239-938-3555.

A member of our medical records staff will call you during our normal business hours, Monday through Friday 7:30AM to 5PM.
If you need to reach us by phone, please call 239-938-3511.

Florida Radiology Consultants, L. L. C.

63 Barkley Circle, Suites 100 & 101, Fort Myers • 6311 South Pointe Blvd., Suite 600, Fort Myers