Provider Upload

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

Patient NameEnter full name
Patient DOBDate Of Birth
Patient SSNLast 4 SSN
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)
0 / 400

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

Subscribe To Our Newsletter

Join our mailing list to receive the latest news and updates from our company.

You have Successfully Subscribed!