Medical Index and Copy Service Request

Request Date:
Analyst Name:
Number of Copy Sets:
Analyst Email:
Please check one:  
 Paper File PDF via Email (EFlo documents) Non-Litigated Case

Due Date:
Analyst Phone:
   
   
   
   
   
   
 
Information will appear on medical index as it is specified below:
Name of Injured:
Claim Number:
WCAB Number:
Date of Injury:
   
Non-Medical Records to Appear on Medical Index: (Please check documents to be included)
(Date)
(Date)
(Date)
(Date)
(Date)
 
Delivery of Medical Records: (For delivery of medical records please specify address for delivery)
1. Name of Facility/Provider:
Address:
Phone:
   
2. Name of Facility/Provider:
Address:
Phone:

   
If you do not receive a confirmation email within 24 hrs. please contact us at 951.779.1630.