Online Ordering – Authorization Request Form

To place an order please fill out this order form

Records Requesting:

Medical RecordsEmployment RecordsSchool RecordsOther Record Type

If Other Record Type was checked, Please indicate which type below

Method of Delivery:

Online ViewingPaperCD

Firm / Attorney Information

Requesting Firm:

Attorney Name:

Address Information:

Contact Information

Contact Person:

Phone Number:

Contact Email:*

Patient Information

Records of:*

AKA:

Date of Birth:

SSN:

Date of Accident:

Facility Information

Facility 1 Information

Facility Name:

Facility Address:

Facility Phone Number:

MRN: (if applicable)

Records Requesting:

RecordsBillingFilms

Requested Dates of Service:

Facility 2 Information

Facility Name:

Facility Address:

Facility Phone Number:

MRN: (if applicable)

Records Requesting

RecordsBillingFilms

Requested Dates of Service:

Facility 3 Information

Facility Name:

Facility Address:

Facility Phone Number:

MRN: (if applicable)

Records Requesting

RecordsBillingFilms

Requested Dates of Service:

Facility 4 Information

Facility Name:

Facility Address:

Facility Phone Number:

MRN: (if applicable)

Records Requesting

RecordsBillingFilms

Requested Dates of Service:

Facility 5 Information

Facility Name:

Facility Address:

Facility Phone Number:

MRN: (if applicable)

Records Requesting

RecordsBillingFilms

Requested Dates of Service:

Special Instruction:

(If more facilities are needed, please fill out another form)

If you would like to attach a release or other relevant document, Please do so below. If not, then please fax or email the documents to us

File Attachments:

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