Important Notes:

1. Please use a unique email for each patient. If you are representing one or more patients including yourself, you have to provide separate email address for each patient.

2. Please ENTER SSN, last 4 digits only.

3. Date of birth, please use provided calender.

4. * indicates all fields are mandatory.

5.Please make sure you enter the Email accurately to avoid medical information being seen by others.

6.If you need to change the email address, please visit the PCS front desk, or email us at recordrequest@pcs-michigan.com

First Name(*) :
Last Name(*) :
Date Of Birth(*) :
Last 4 digit SSN(*) :
Medical Record Number(Account No)(*) :