Requestor's Information

Name

Company

Address: City State Zip

Telephone

Fax

E-mail results and invoice to

Claimant's Information

Claim #

Name

Type of Claim

Sex:

MALE

FEMALE

Date of Birth

Address

City

State

Zip

Search Areas (60 mile radius)

DOL

Injury

Please Check Appropriate Search Request

Hospital search (10 hospital limit):

Pharmacy search (10 pharmacy limit):

Chiropractor search (10 chiropractor limit):

Clinic search (10 clinic limit): Specify Type:Walk-ins & urgent care

Doctor search (10 doctor limit):

MRI search (10 facility limit):

Dental search (10 facility limit):

Other (please specify): Radiology*

Would you like to extend search beyond 10? If so, how many?**

OTHER*		Beyond 10?**

Locations of Previous Treatment

Name	Address	Telephone	Dates	Do you want these facilities included in your search?