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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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    Attorneys Reliable Legal Solutions

    2411 Saint Francis Drive
    Sacramento, CA. 95821

    Phone: 916-335-9531
    Fax: 916-914-2203

    Email: attorneysreliable@gmail.com

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