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2. Medical Records Payment Form

   Please use this form if you received an invoice regarding the release of medical records for former residents of Portage Manor

4. Requestor's Name*
5. Former Resident's Name*
7. Invoice Number*
9. Invoice
   Medical Records
10. # of Requests
11. Invoice Amount*
12. Shipping Cost
14. Taxable
16. Online Payment Fees:

    Online payments are processed by Forte. A fee of 2.55% or $1.50 (whichever is greater) will be assessed for all credit card payments. Electronic Checks are also accepted, and will be assessed a flat $1.25 for any payment under $50,000. The appropriate fee will be added to the total cost of your payment.

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17. Calculate Totals Proceed to Checkout

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