Please provide as much information as possible. Any fields that are marked as required (*)can not be left blank. Once completed you may click the Submit button at the bottom of the page and your request will be processed immediately. If you have any questions you may contact our office at Phone:(800) 537-4390  / Fax:(954) 474-1640.

Requestor Information

*Name *Company

Address City State Zip

*Phone Ext Fax Email


Claimant Information

*Last Name *First Name

Address City State Zip

Phone Date of Birth SSN Date of Acc.

*Claim File Number Insured Name

Insured Address Insured City Ins. State Ins. Zip


Treating Doctor Information

Dr. Name Dr. Address Hosp./Group

Dr. City Dr. State Dr. Zip Dr. Phone Dr. Fax


Claimant Attorney Information

Name Firm Name

Address City State Zip

Phone Fax Email



Defense Attorney Information

Name Firm Name Paralegal

Address City State Zip

Phone Fax Email


Service Information

*Coverage  *Service Req. Other Ser. TAT

Specialty/s Required Medical Records

Issues to be addressed

Special Instructions