Note: Fields marked with * must be completed.  Fax Medical records to (702) 925-2470.
Patient Details:
Patient's Name*: SSN: - -
Patient's Address: City:
State*: ZipCode:
Patient's Phone: DOB*:
DOI*:
Type of Case: Reason for EFA:
If Other: If Other:
DX Complaints*:    
Employer Details:
Employer:
Employer's Address: City:
State: Zip:
Employer's Phone: Fax:

Referrer Details:
Referred By*: Referrer's Phone*:
Fax: Referral's Email:
Address: City:
State: Zip:
Check if you want site specific treatment recommendations in the report (if applicable)
Send Results To:   Referral:  Adjuster:  Other:  
Payment Preauthorized*:     Yes:     No:  
Check here if Person Authorizing is same as Referrer
Else, Person Authorizing: Title:
Phone:
 
Referral Comments:

Insurance Details:
Check here if same as referrer
Insurance Co*: Adjuster:
Address: City:
State: Zip:
Phone: Fax:
Policy/Claim#: Group#:
Sending Medical Records?    Yes:     No:  

Physician Details:
Check here if same as referrer
Physician:
Phone: Fax:
Address: City:
State: Zipcode:
Physician to be Contacted by:    InsightDx:     Other:  
Patient to be Contacted by:       InsightDx:     Case Manager:     Adjuster:

Attorney Details:
Attorney: Address:
City: State:
Zipcode: Send  Results to:
Phone: Fax:
 

Fax Medical records to (702) 925-2470.
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