Search Request Form

We make requesting a search simple. All you have to do is complete the form below and click on the "submit" button. We will take it from there.

Your search(es) will be completed in just two to three days (some searches within hours) and sent to you by email along with your invoice.

For pricing please call 317-861-8443.

 

Requestor's Information
	* required fields
	Full Name: *
	Company Name:
	Address:
	City:
	State:
	Postal Code:
	Telephone: *
	Fax:
	Email Address: *
Claimant's Information
	Claim #:
	Full Name:
	Type of Claim:
	Gender:
	Date of Birth:
	SSN:
	Address:
	City:
	State:
	Postal Code:
	Address to be search if different than above:
	DOL:
	Injury:
Please Check Appropriate Search Request
	Check here if search/searches needed to be completed on a rush bases ($50.00 per search.)
	Hospital search (11 hospitals):
	Pharmacy search (11 pharmacies):
	Chiropractor search (11 chiropractors):
	Clinic search (11 clinics):
	Physician search (11 doctors): Specify type:
	Imaging search (11 facilities):
	Dental search (11 facilities limit):
	Therapy search (11 facilities limit):
	Storage Facility search (11 facilities limit):
	Other (please specify):
	Claimant Information Search ($20.00 per search.)
	Comments:
	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.

 

 

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