RECORDS REQUEST FORM
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SCANDOC Imaging, Inc.
500 Superior Avenue • Suite 320 • Newport Beach • California 92663
Phone: 949 650 9595 • Fax: 949 650 9594
Senders E-mail (required) :
RUSH WCAB REQUEST CIVIL REQUEST
APPLICANT/PLAINTIFF INFORMATION
NAME:
AKA:
ADDRESS:
D.O.B.:
SSN:
BILLING INFORMATION
INSURANCE CARRIER:
ADDRESS:
PHONE:
CLAIM #:
ADJUSTER:
REQUESTER INFORMATION
REQUEST BY:
FIRM:
ADDRESS:
PHONE:
FAX :
REPRESENT:
APPLICANT
PLAINTIFF
DEFENDANT
OTHER
CASE INFORMATION
CASE#:
INJURY DATE:
EMPLOYER:
ADDRESS:
EMPLOYER'S DEFENSE:
ADDRESS:
NUMBER OF SETS:
DELIVER RECORDS TO:
RECORD TYPE ADDRESS PHONE
SPECIAL INSTRUCTIONS
         

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