Provider Upload

If you are a records provider delivering records to Records Rescue on behalf of a patient, please complete this form.

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Patient NameEnter full name
Patient DOBDate Of Birth
date_range
Patient SSNLast 4 SSN
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Patient Files
cloud_uploadUpload up to 10 Files

Hint:  Files have finished loading when the filename appears within the green bar followed by an "X" at right.

CommentsMore details (optional)
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Should you have any questions or difficulties with this form please call us at (877) 557-3728 for assistance.

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