Request Services

Thanks for coming to our website to order your service. Please note that any fields with a red asterisk (*) must be filled out in order to move to the next page of the request form. We appreciate your business!
First Name*
Last Name*
Company*
Address
City
State
Zip Code
Phone Number*
Fax Number
Email Address*
Please select one:*
- I am the person handling this claim and I am requesting this service.
- I am requesting this service on the behalf of another person. (ie. Paralegal ordering for attorney)
What is your role in this service request?*
Other:

	Phone: 952-253-6600 PhoneToll Free: 1-800-804-4008 Medical Records Direct: 952-253-6603
	Fax: 952-253-3900 Medical Records Fax: 1-888-645-1230

Cover letter and Medical Records