Online Record Request Form

Please fill out as much information as you can and hit the submit button at the bottom. Once we begin to process your order, you will receive a confirmation e-mail. If you do not receive a confirmation e-mail within 24 hours, please resubmit your request, or contact us at (661) 273-3698.

Note: all fields marked with an asterisk are required in order to submit.

Please provide the best number to contact you.
Please provide the best e-mail to contact you.
If the claimant now, or has ever, gone by another name, please provide that name here (multiple names should be seperated by commas).
If the claimant is represented by counsel, please provide his/her information here (i.e. name, phone, address, etc.)
Please provide the name(s) and address(es) of the location(s) from where you're seeking records. (Sample Kaiser Permanente San Jose: 250 Hospital Pkwy, San Jose, CA 95119 )
Please provide the name, address, and telephone number of the defense attorney(s) here.
If there is any further information or special instructions you'd like us to know, please provide that here.
If you have any documents you'd like to submit (i.e. an authorization form), you can do so here,