test company
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test fortw, Indiana 46804 usa
E 40° 0" N 30° 0"
Telephone: (260) 436-0259

For Patients Requesting Their Records:

Click on the button below to fill out the on line request form.  After you submit the form, a completed form will appear on your screen.  Please print the form and sign.  The signed form and a copy of your driver’s license must be faxed, emailed, or mailed according to the directions on the form.

For All Other Parties Requesting Records:

Click on the button below to fill out the on line request form.  After you submit the form, a completed form will appear on your screen.  Please print the form and sign.  The signed form must be faxed, emailed or mailed according to the directions on the form. 

You may also use your own records request form.  You can fax your signed form to

(614)583-9042.

If you have questions regarding a request already in progress, please call

Phone # (614)591-3221