Medical Records Request

Request Patient Portal Access

Fill out this form and we’ll contact you soon with your portal details.

Name(Required)

First Last

Email(Required)

Phone(Required)

Which clinic were you seen at?(Required)

Date of Birth

How do you want your results?

Email me my results

I’ll view my results through my new patient portal

Message

Request Medical Records

Attorney Name(Required)

First Last

Law Firm Requesting Records(Required)

Law Firm Phone Number(Required)

Attorney Email(Required)

Paralegal name (optional)

Paralegal email (optional)

Client Name(Required)

First Last

Client Date of Birth(Required)

Which clinic are you requesting reports from?(Required)

Please choose one(Required)

Client has direct lien with First Choice Imaging

Client is working with a medical funder

Other

Medical Funder(Required)

Which records are being requested?

Request Attorney Portal Access

Fill out this form and we’ll contact you soon with your portal details.

Attorney Name(Required)

First Last

Firm Name(Required)

Attorney Email(Required)

Phone(Required)

Paralegal Name

Paralegal Email

Work with Us

Law Firm Name(Required)

Attorney Name(Required)

First Last

Law Firm Phone Number(Required)

Attorney Email(Required)

Paralegal Name (optional)

Paralegal Email (optional)

Which clinic would you like to work with?(Required)

What are you interested in?

Direct lien

Medical funding

Have a question? Contact us.

Provider Name(Required)

First Last

Clinic Name

Clinic Phone(Required)

Clinic Fax Number(Required)

Email(Required)

Location inquiring about(Required)

MA

Your Message

Report Request – Providers

Patient Name(Required)

First Last

Date of Birth(Required)

Location the MRI was done at(Required)

Provider Name(Required)

First Last

Clinic Name

Clinic Phone(Required)

Clinic Fax Number(Required)

Email(Required)

MA

Reports being requested / Message

Portal Request – Providers

Tell us how we can help

I forgot my password to PACS

I need to set up access to PACS

What is your PACS username?(Required)

Provider Name(Required)

First Last

NPI(Required)

Provider's mobile phone number for critical findings(Required)

Email(Required)

Clinic Name(Required)

Clinic Address(Required)

Street Address Address Line 2 City State ZIP Code

Clinic Phone Number(Required)

Clinic Fax Number(Required)

Name of MA / Nurse

First Last

MA / Nurse Email

Message

What clinic(s) are you needing access to?

Logan

Tooele

Sandy (Wasatch)

St. George

Report Request – Patients

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Clinic you were seen at(Required)

What records/reports are you requesting?

Medical Records Transfer Request

Which First Choice Imaging location are you inquiring about?(Required)

I'm requesting my records be transferred…(Required)

TO First Choice Imaging from another office

FROM First Choice Imaging to another office

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Please tell us the name of the doctor/clinic where you would like us to send your records.(Required)

Please provide the name of the clinic and provider you would like us to request records from.(Required)

What records are being requested?(Required)

Clinic you were seen at(Required)

Records you are requesting(Required)

Radiology Reports

Billing Records

How would you like to receive a copy of your records?(Required)

Email

Mail

Name(Required)

First Last

Date of Birth(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Tell us which records you are requesting and the date of service.(Required)

Medical Images Request

Clinic you were seen at(Required)

I want:(Required)

Access to images through Patient Portal

Access to images through email link

Images on a disc/CD

How would you like to receive your disc?(Required)

I will pick the disc up in the office

Please mail my disc to me

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Tell us which imaging you are requesting and the date of service.(Required)

Medical Records Request

Salt Lake City

Tooele

Logan

MRI Clinic

CT Clinic

St. George - Open Now

Open MRI

Request Patient Portal Access

Request Medical Records

Request Attorney Portal Access

Work with Us

Have a question? Contact us.

Report Request – Providers

Portal Request – Providers

Report Request – Patients

Medical Records Transfer Request