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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:  Pick a date
  To:  Pick a date
 
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 :
   
     
   

 


ph: 630.305.8108 I fax: 630.305.8199 I e-mail: info@alphareview.com

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