Requestor Satisfaction Survey Thank you for requesting medical records. To better serve you in the future, please take a moment to complete the survey below. Question Title * 1. In which state is your healthcare provider? AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Question Title * 2. Enter the name of the hospital or clinic from which you requested records. Question Title * 3. (Optional) Please enter your invoice number if available (found on top right corner of invoice). Question Title * 4. Did you speak with a live representative(s) in the process of requesting records? Yes No Next
