Record Express, LLC :: Order :: Attending Physicians Statements

ATTENTION! If you are using Internet Explorer 8 or higher and are having difficulties filling in dates & numbers, you must click on the Compatibility tab at the top of your browser that looks like this:

Attending Physician Statement Order Form

SECTION A

* Required Fields

* Customer Name: Policy #:

Date:

Address1:

* Phone:

Address2:

Fax:

Contact Person:	Direct Dial:	Email:
Assistant/Secretary:	Direct Dial:	Email:

Billing Address(if different):

Bill To:	Patient/Claimant	Insurance <>

Billing Type:	LTD	Other

SECTION B

* Name of Insured:

* SSN# AKA:

* DOB:

DOD:

Daytime Ph: Evening Ph:

Address1:

Address2:

Policy Number :

Type of Policy:	Life Insurance Applicant	Worker's Compensation
	Disability Insurance	Death Benefits / Life Insurance Claim

SECTION C

MEDICAL RECORDS

Provider Name :

Phone:

Provider Address :

Check all that apply:

Medical Records Chart:	Billing Records	Full Chart	Abstract
X-Rays:	Copy of Films	Original Films
CT Scan :	Copy	Original
PT Scan :	Copy	Original

Pathology Type :

Blocks

Slides

Specific dates of records from: to:

Special Instructions (Specific):

To Add Additional Medical Records Click Here:

Special Instructions (General):

* Please Fax Authorizations to: (513) 685-7330 or Email to: info@recordexpressllc.com

Select the method you will use to send authorizations:

Fax