Records Request - Prime Solutions

Order Date:

Court date:

1075 N. Tustin St, #6382 Orange, CA 92863
Phone: (714) 619-2444 Fax: (714) 619-2445
records@primesolutionsus.com
www.primesolutionsus.com

Workers' Compensation

Civil / Personal Injury

Add to Existing Order: ADJ

* Firm Name: Attorney:

Street: City: State: Zip Code:

* Phone: Fax: * Email:

Authorized Requesters' Name: Signature:

Name:

AKA:

DOB: SSN:

ADJ#:

DOI(s) From: DOI(s) To:

Name:

Street:

City: State: Zip Code:

Phone: REQUEST RECORDS FROM EMPLOYER

Name: Claim Number: Bill Requester

Street: City: State: Zip Code:

Phone: Fax: Request Records form Insurance Carrier

1 Name: Record Type:

Street: City: State: Zip Code:

Phone: Fax: DATE RANGE:

2 Name: Record Type:

Street: City: State: Zip Code:

Phone: Fax: DATE RANGE:

3 Name: Record Type:

Street: City: State: Zip Code:

Phone: Fax: DATE RANGE:

SUBMIT

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Submit Records Request Form by email to records@primesolutionsus.com or fax (714)619-2445