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Subpoena | |
Records are being requested under subpoena, discovery request, or other court order. |
Disability / Govt Benefits | |
Records are being requested in relation to a claim for SSA disability benefits or other government benefit program. |
Workers' Compensation | |
Records are being requested in relation to a claim for workers' compensation. |
Investigation / Assessment | |
Records are being requested in relation to an investigation by government agency (e.g. DSS, DCF, CPS). |
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INVOICE
Facility | RQ-ID |
Patient Name | Date of Birth |
Description | Per | Qty | Fee |
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TOTAL | |||
PAYMENT | ||||
BALANCE |
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