Quality Urgent Care

quc@qualityurgentcare-riverview.com

(813) 741-2592

Emergency Medical
Condition (EMC/MVA)
Request

Please contact us directly via email: quc@qualityurgentcare-riverview.com to expedite the visit. Our offices are available 8 AM - 8 PM daily.

Quality Urgent Care Location (Name & Address):

Check Type of Request:

EMC OR MVA

Patient Name:

Insurance Carrier:

Patient Date of Birth:

Medical Claim #:

Patient Phone Number:

Date of Accident:

Referring Office/Organization

Were you referred to us?

Yes No

If YES, please provide the following information:

Office/Organization Name:

Designated Representative Name:

Phone Number:

Fax Number:

Attorney Information

Is there an attorney assigned to the case?

Yes No

If YES, please provide the following information:

Law Office Name:

Attorney Name:

Phone Number:

Fax Number:

Request for Medical Records

This signed form authorizes the release of medical records information necessary for billing or continuity of care. If there are specific records needed for this patient, please check information to be released:

All Records If specific item(s) requested, please specify:

Preferred method to receive requested records:

Secure Fax Mail

Patient (or Authorized Representative) Signature

Date

Quality Urgent Care

Emergency Medical
Condition (EMC/MVA)
Request

Referring Office/Organization

Attorney Information

Requested Services

X-ray

Medication Management

Request for Medical Records