Requests

What Do You Need Help With? *

Requester Information

First Name *

Last Name *

Phone *

Email *

Law Firm *

Law Firm ID Number

City

State

Paralegal/Case Manager Information

Paralegal/Case Manager Full Name

Paralegal/Case Manager Phone Number

Paralegal/Case Manager Email

Comments

Patient Information

Patient Full Name *

Date of Birth *

Select Date of Accident *

Patient Email

Patient Phone

HIPAA Authorization

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Before any records can be released, please upload your clients' HIPAA authorization form. If needed, download the Chiro One-approved HIPAA Authorization form here.

Payoff Request

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Letter of Protection / Letter of Representation

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Supporting Documents

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

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