Document Image Request Form

Please provide us with the following information and we will deliver the requested image(s) to you within two business days.
 

Company Name:
Requested by:
	Name:
	Phone Number:
	Email:
Claim Number:
Claimant Name:
Provider Name:
& Tax ID Number:      (if known)
Date(s) of Service:
	From:
	To:
Document(s) Requested
		Explanation(s) of Review Only
		Document Image(s) Only
		Both Explanation(s) of Review and Document Image(s)
How would you like the document(s) sent to you?
		Email (provided above)
		Fax Number :