Request a Medical Letter

Request a Medical Letter

Tell us what you need the letter for and provide any required details.
Letter fees are based on the complexity of the request and the time required to prepare the letter. If a fee is not listed, a member of our team will contact you within one business day to provide the cost.

Once payment is received, we will begin processing your request. The standard turnaround time for completed letters is five (5) business days, beginning on the date payment is received.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method to Receive Completed letter
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Please select the type of letter you are requesting. Unless otherwise specified, fees are determined by the complexity of the request.

Other
Recipient Information (who should the letter be addressed to, if not yourself?)
Form fees are based on the complexity and time required to complete each form. Once we receive your form, a member of our team will contact you within one business day to inform you of the fee.

After payment is received, we will begin processing your request. The standard turnaround time for completed forms is five (5) business days, beginning on the date payment is received.
Additional Details or Special Instructions. Please include all information you would like included in your letter. If a revised or additional letter is required because necessary information was not provided with your original request, an additional fee may apply.
Please select one of the following options to let us know when you need your form completed. We will make every effort to meet your requested timeframe, based on provider availability.:
File Upload

Cancelof
Signature
Disclaimer: Submission of this request does not guarantee that the requested form or letter will be completed. The decision to complete any form or letter is at the discretion of the patient’s provider and will be based on the provider’s clinical judgment, available information, and applicable policies.
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