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Attending Physician Statement Order Form

SECTION A

* Required Fields

 * Customer Name:

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:
 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 :
Slides
Specific dates of records from: to:


Special Instructions (Specific):

To Add Additional Medical Records Click Here: