Medical Records Order Information:
* required fields
Claim Number: * Loss Date: * Insured:*
Your Name: * Your Phone:
Your e-mail: Company:
Mailing Address
Please fax signed medical authorization to: 512-276-6768
Records: Itemized Bills: Both: (If billing is at a separate location, additional retrieval fee may apply)
Injured Party: DOB: SS#:
Medical Provider: Provider Phone:
Physician: Treatment Dates:
Special instructions (add additional injured parties and providers):
