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Work Comp Document Request Form
Please allow 24 to 48 hours to facilitate your request.
If you are requesting multiple dates of service for one patient, please submit your request to our medical records department at
medrecords@doclv.com
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* Indicates required question
Which document are you requesting?
*
PPR (Physician's Progress Report)
Dictated report
Both: PPR and Dictated report
Requests for Services (ex: Diagnostic, PT, DME, Surgery, Injections, etc.)
Which Date of Service are you seeking?
*
Your answer
Requestor Name
*
Your answer
Requestor Email
*
Your answer
Requestor Fax Number
*
Your answer
Injured Worker First and Last Name
*
Your answer
Injured Worker Date of Birth
*
Your answer
Comments
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