RECORDS REQUEST
* = required fields
Requesting Attorney*
Firm Name*
On Behalf Of*
Defendant
Plaintiff
Other
Assistant/Paralegal
Address*
City*
State*
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip*
Phone*
Fax
Email Address*
NECESSARY INFORMATION
Name on Record/Patient Name*
Date of Birth*
Social Security* #
AUTHORIZATIONS
Authorizations*
Obtain from opposing counsel
To follow by mail
To follow by fax
Attached as PDF
None required
You can upload files in the next step.
DELIVERY METHOD
Format *
Standard (Paper)
Online respository only (Discount applies)
Additional Copies
Send a copy of all records to
Adjuster
Other Counsel
Adjuster
Email Address
Address
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Format
Paper
CD-Rom
Online Repository
Other Counsel Name
Email Address
Address
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Format
Paper
CD-Rom
Online Repository
Misc/Special Instructions
CASE INFORMATION
Case Caption
vs.
Court
Case Number
Judge
Date of Incident
Opposing Counsel Name
Email Address
Address
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Please provide Opposing Counsel with Copy (paper records only)
Additional Counsel
You can attach a list of Counsel (optional) on the next screen.
BILLING INFORMATION
Bill To*:
Above
Third Party
Third Party*
Email Address*
Address*
City*
State*
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Claim # or Case Billing Ref. #*
PROVIDER INFORMATION
Total No. of Providers
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Provider 1
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 2
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 3
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 4
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 5
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 6
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 7
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 8
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 9
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 10
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 11
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 12
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 13
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 14
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 15
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 16
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 17
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 18
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 19
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
Provider 20
Address
Address 2
City
State
---
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Phone
Fax
Records Requested/Duces Tecum
Any and all office records including, but not limited to, office visits, correspondence, radiology reports, pathology reports, pulmonary function tests, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
any and all information contained in the employment file of the above captioned individual including but not limited to job descriptions, promotions, discipline, attendance, payroll, medical, injury and/or Workers' Compensation records.
Any and all billing records, including but not limited to, any information pertaining to write-offs, set-offs, adjustments or negotiated amounts.
Any and all records
Any and all medical records, including but not limited to office notes, diagnostic studies, tests, reports and correspondence pertaining to the above captioned individual.
ANY AND ALL HOSPITAL RECORDS, INCLUDING BUT NOT LIMITED TO, OUTPATIENT, INPATIENT, CLINIC OR ER VISITS, DISCHARGE SUMMARIES, PROGRESS NOTES, CONSULTS, OPERATIVE, PATHOLOGY & X-RAY REPORTS, AND PULMONARY FUNCTION TESTS
ANY AND ALL MEDICAL RECORDS, INCLUDING BUT NOT LIMITED TO, OFFICE VISITS, PHONE RECORDS, HOSPITAL RECORDS OR OUTPATIENT REPORTS, CORRESPONDENCE AND CONSULTS
Any and all medical and/or psychological records, files, or information in your possession or control, including, but not limited to, office visit notes, correspondence, radiology reports, pathology reports, laboratory reports, pulmonary function test reports, consultations, special diagnostic procedure reports, and hospital records that are part of the office record.
ANY AND ALL OUTPATIENT, CLINIC, ER VISITS AND/OR PHYSICAL THERAPY RECORDS. FOR ADMISSIONS: DISCHARGE SUMMARIES, HISTORY & PHYSICAL AND CONSULTATION REPORTS ONLY.
If yours is not listed, please enter it in the box below.
Please Include
Specify Body Part and/or Range of Dates
None
Billing
XRay
CTScan
MRI
Please Include
Rush
Notarize
© 2021 Cefaratti Group, Inc. All rights reserved. | 4608 St. Clair Avenue | Cleveland, OH 44103