Workers Compensation Order Form

Kopy-Kat
P.O. Box 1029
Brea, Ca. 92821
(800) 660-1946 (714) 990-6100 - Fax (714) 990-6126
E-MAIL: neworders@kopykat.net

If You Have A Field Office Number Please Enter Here
Field Office Number:
Firm Name Order Date
Ordered By Bill To / Carrier Carrier Ordering Firm
Other Split Bill
Email Address Adjuster's Name
Address Address
Phone Phone
Fax Fax
Firm File # Name of Insured
Contact Person Claim File #
Rush (Yes If Checked) Date of Loss (MM/DD/YYY)
Date Needed    

 

Subpoena
Prepare SDT/
Authorization Faxed/Mail
Opposing Counsel
Applicant Address
Defendant Who Represents Records Subject
Case Number Additional Counsel
You Represent Applicant Defendant    

 

Subject's Name X-Ray Fee Limit
A.K.A. X-Ray Breakdown
Date of Birth


(MM/DD/YYY)

Number of Copies

Digital Paper

Soc. Sec. No


(ddd-dd-dddd)

Add'l Set/s To: (please specify address)




Doctor Defense

Applicant Attorney

Adjuster Expert

Facilities

Location Location
Address Address
Phone Phone

Special Instructions / Type of Records

Special Instructions / Type of Records

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 


Location Location
Address Address
Phone Phone

Special Instructions / Type of Records

Special Instructions / Type of Records

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 


Location Location
Address Address
Phone Phone

Special Instructions / Type of Records

Special Instructions / Type of Records

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 


Location Location
Address Address
Phone Phone

Special Instructions / Type of Records

Special Instructions / Type of Records

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 


Location Location
Address Address
Phone Phone

Special Instructions / Type of Records

Special Instructions / Type of Records

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 


Location Location
Address Address
Phone Phone

Special Instructions / Type of Records

Special Instructions / Type of Records

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)

 

Medical X-Ray Films Bills Employment

Insurance (please provide claim # or insured name)

Other (please specify)