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