Gather the following information before proceeding with this online process. 

• First and last name patient/client
• Last four SSN of patient/client
• What information you are requesting regarding the patient/client
• Facility / office name
• Facility / office address
• Facility / office phone number
• Facility / office fax number
• Facility / office email address
• Facility / office contact person
• Confirmation from Facility they will comply with request/time frame
• Patient / client first name
• Patient / client last name
• Patient / client last four digits of SSN
• Relationship of requester of patient/client

By clicking on the Faxing Services button below you are agreeing that all the above information and confirmation have been gathered and completed.