New Form (April) Requestor Information First Name Last Name Company name Phone Number Fax Number Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Claim Information Do you have a valid HIPAA-Compliant Release for this claimant? Yes No Upload HIPAA-Compliant Release Documents (Optional) Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 33.55MB Claim Number Type of Claim Insurer DOL Injury Claimant Information First Name Last Name Gender Male Female Date of Birth Social Security Number Phone Number Search Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Would you like us to perform a search(es) at an additional address? No Yes Additional Search Address Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Choose Search Claimant Information Search Hospital Search Chiropractor Search No Yes Pharmacy Search Pharmacy Search Options Pharmacy Search Options Regular Deluxe Super Deluxe Clinic Search No Yes Primary Care Physician Search No Yes Imaging Search No Yes Dental Search No Yes Therapy Search No Yes Storage Search No Yes Psychiatric Search No Yes Orthopedic Search No Yes Nerology Search No Yes Psychiatric Search Documents Needed Upload Medical Authorization Release Documents * Drop a file here or click to upload Choose File Maximum upload size: 33.55MB A medical authorization is required to provide a psychiatric search. Please upload the necessary documents to begin. Specialty Search Example: Cancer Center, Dermatology, Home Health Care, Long Term Care. Comment By submitting this form, requestor represents: (a) the claimant is from a state in which HIPAA privacy rules, via the state worker's compensation laws, allow the requested medical information to be obtained without a medical authorization.; or (b) it has obtained from claimant an authorization for release of medical records complying with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and that authorizes Search Pros, Inc. to obtain medical records from health care providers.
