Trailblazer Services Request Form

Request Form

Please take a moment to fill out this request form. Requests will be sent out within 24-48 hours, except in cases where the date of injury is recent; in such instances, they will be sent out two weeks from the date of injury.
Please utilize this Jotform for all Medical Records, Medical Billing, and Balance Verification Requests.

For Subrogation Requests please click HERE.
Today's Date

MonthDayYear
Date
Firm Name
Requester Name*
Requester Email*
example@example.com

Client Information

Please enter all fields
Client First Name*
Client Last Name*
Date of Birth*

MonthDayYear
Date
Gender *This is required for all Physician Emergency Services and Radiology Billing Requests

MaleFemaleOther
SS
This is required for all Physician Emergency Services and Radiology Billing Requests
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number
Please enter a valid phone number.
Date of Injury*

MonthDayYear
Date

Provider Information

Provider Name is required. Address and phone number are optional. If you don't know it, please write N/A.
Provider Information*
Reproductive Health Care Attestation:

All 3rd party processors for hospitals and ambulance require a signed Attestation that clearly states the requested use or disclosure is NOT for the prohibited purposes described in the HIPAA Privacy Rule Final Rule to Support Reproductive Health Care Privacy.

We have received your firm's signed attestation; however, we require clarification as we are not privy to the specific case facts, we need confirmation to ensure that the PHI is NOT being used for any purpose prohibited under the HIPAA Privacy Rule.
Please indicate by checking the appropriate box below whether this authorization is being utilized for reproductive purposes in accordance with linked policy above.*

The protected Health Information is NOT to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care or to identify any person for such purposes.The purpose of the use or disclosure of protected health information IS to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive healthcare, or to identify any person for such purposes.
Comments

Please upload Authorization/DL/Insurance Card/Birth Certificate/Other Documents*

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Request Form