To download a form, just click on a link below. You will need Adobe Acrobat Reader to open all files below.
For all WC request, please attach:
1) Application of adjudication 2) Notice of representation 3) HIPPA authorization form
For PI request, please attach:
1) HIPPA authorization form
Referral Form | Electronic Request Form | Download PDF |
Affidavit | Download PDF | |
Universal Copy HIPAA Complaint Authorization for the release of patient information | Download PDF |