Third Party Order Form (print and include with cheque)

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Date: {date_mdy}To:
RSRS – Record Storage & Retrieval Services Inc.
111 St. Regis Cres. S.
Toronto, ON M3J 1Y6

From:
{Contact First Name:22} {Contact Last Name:23}
{Organization Name:16}
{Street Address:18}
{City:19}, {Prov.:20} {Postal:21}
Email: {Email address:24}
Telephone: {Phone Number (include ext. #):25}
Fax: {Fax Number:26}
Your file reference (if any): {Your File Reference or Claim Number (optional):10}

For: Retrieval of Medical Record
From the medical practice of Dr. {Doctor’s First Name:1} {Doctor’s Last Name:2} in {Doctor’s City:3}, {Doctor’s Province:4}.
Medical Record of {Patient First Name:5} {Patient Last Name:6}
D.O.B.: {Patient Date of Birth:7}
Date Last Seen: {Date patient was last seen by doctor, (if known):8} {or choose an estimated date range when patient was last seen by doctor (choose only one):9}

Service

Initial Medical Record Search

Look-up your province and find the total cost of the initial search fee, including sales tax, in the right column:

tax_question_2column

Special Requests: {Comments:29}

Remember to include:

[ ] This order form (print)

[ ] Release of information, signed by patient (or legally authorized representative)

[ ] Cheque for $50.00 plus sales tax made payable to “RSRS Inc.”

Please note:

Searches are not initiated without receipt of this fee.
RUSH requests should be made by contacting us at 1-888-563-3732, ext 641, (additional charges apply).
Once the record has been found, a Copying and Delivery Fee is charged separately. RSRS will send you an invoice for copying and delivery once the record has been located and assessed.

Thanks you for your order. We will get in touch with you shortly.

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