Forms / Contact

/Forms / Contact
Forms / Contact 2017-08-28T00:43:57+00:00

Forms:

Below, you will find some useful forms to be provided to plaintiff’s counsel for execution and, where noted, notarization in order to obtain a claimant’s prior medical / legal / employment / wage information. These forms, showing our name as a c/o for your firm, will reduce the importance of the Letters of Representation that we always include with our requests and should reduce or eliminate receipt of invoices or other correspondence by your office when that information should, in fact, go through us, in your stead.

  • Standard HIPAA authorization
  • FDNY – Requires original notarized HIPAA along with ambulance call report form with as much information filled out as possible.
    • Please note that not all 911 calls are transported by the FDNY so, if possible, ask if it was, in fact, an FDNY ambulance or if it was another service; FDNY will simply reject requests for non-FDNY ambulance reports without providing the reason.
  • Empire / Blue Cross Blue ShieldALWAYS requires the original notarized HIPAA authorization.
  • AIG – Requires Subpoena along with HIPAA
  • Medicare / MedicaidALWAYS requires the original notarized HIPAA authorization and form.
  • Workers Comp – Requires OC110A original form with Imedview in the body where it says to send records to.
  • Internal Revenue Service – Requires specific form; transcripts or copies of returns will only be forwarded to the party named on Form 4506T or Form 4506, respectively.
  • Social Security Administration – Requires their own Consent for Release of Information.
  • Instructions on how to enter a case directly into Imedview, Inc.’s system can be found here!

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  • Fax: (866) 791-7030