Service Request Form

 

Pane and Associates Document Reproduction Services

A Disabled Veteran Owned Business

DVBE# 0006525

P.O. Box 191452
Sacramento, CA 95819

 

Entity Requesting Records:

 

Address:

 

City:

 

State:

 

Zip:

 

Representative:

 

Phone:

 

Fax:

 

E-mail address:

 

I

 

,  authorize Pane and Associates Document Reproduction Services to

obtain records of

 

On my behalf from the office of

 

Located at

 

Date(s) requesting records from

 

 

Including

c Progress Notes        c History/ Physicals                c Lab Reports

c X-Ray Reports        c Billing/Insurance                   c Discharge Summary

 

I understand that I will be charged a fee of $25.00 plus .25 per page for such services and Pane and Associates, Document Retrieval Services will notify me if our fee to obtain records exceeds $50.00.

I further understand that if a witness/access fee is demanded by the medical facility that a $2.00 per check charge will apply.

 

Name:

 

Signature:

 

Date: