Get Records via Authorization

Ordered By Information

      Date:     Date Needed:      RUSH: 
     Your Name:
     Atty Name:
     Firm Name:
Street Address:
          City:  State:  Zip Code: 
       Phone #:   Fax #:
        File #:
    Represents:
        E-Mail:
   Confirmation of Order will be sent to the above email address

Ship To Information

Ship To (Same as Above): 
     Attn To  : 
     Firm Name: 
Street Address: 
          City:   State: Zip Code: 
       Phone #:   Fax #:

Additional Ship To:

1) 2)
3) 4)
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99) 100)

Invoice To Information

Invoice To (Same as Above):
      Adj Name: 
     Firm Name: 
Street Address: 
          City:   State: Zip Code: 
       Phone #:   Fax #:
       Claim #:  Date of Loss:
       Insured:

Records Pertain To

Records Pertain To: 
Also Known As:      
Date of Birth:       Date of Loss:
Social Security #:  
Other Information:

Record Locations

Copy All Records at the Below Locations
Copy Only Records for Dates Specified Below

Copy Instructions

Copy  Sets of the Above Records

Medical   Billing    Sign-In Sheets  Dup X-rays   CT Scans
MRI Films Personnel  Payroll         Scholastic   Insurance
Attorney  Public     Other (Specify):

OTHER SERVICES PROVIDED BY Sierra InfoNet:
Index Chart

Special Instructions

How will you provide a copy of the Authorization to Sierra InfoNet?

Attachments

TERMS AND CONDITIONS

1) Upon express written request, Sierra Infonet Services, Incorporated, (Sierra Infonet), will provide third party direct billing as a courtesy to its customers. However, the firm or company placing the order remains primarily and independently responsible for full payment for all services rendered by Sierra Infonet. An exception will be made when Sierra Infonet has entered into a separate written agreement with an insurance carrier.

2) All invoices are due and payable upon receipt, therefore any invoices that are unpaid beyond 30 days will be subject to a service charge of one and one-half percent (1½%) per month.

3) The parties agree that in the event of a breach of this contract by Sierra Infonet, it would be impractical or extremely difficult to assess the actual damages resulting from such a breach. Therefore, in the event of such breach, Sierra Infonet agrees to pay as liquidated damages and not as a penalty, the sum of $50.00 which sum represents a reasonable endeavor by the parties hereto to estimate a fair compensation for foreseeable losses that might result therefrom. In no event shall Sierra Infonet's total liability or responsibility for any damage resulting from breach of this Agreement exceed the sum of $50.00.

4) This Agreement shall be considered as made in Cypress, Orange County, California for purposes of determining venue for any action on said Agreement. The laws of the State of California shall control this Agreement.

5) In the event of any legal action to enforce this Agreement, or to obtain relief from any breach thereof, the prevailing party shall be entitled to an award of reasonable attorney's fees and costs, in addition to any other relief to which he may be entitled.

6) This agreement may not be modified, cancelled or waived, in whole or in part unless expressly agreed to in writing by all parties hereto.

7) This Agreement constitutes a single integrated written contract expressing the entire Agreement of the parties hereto. There are no agreements, representations, or warranties, written or oral, express of implied, by or between the parties, except as expressly set forth herein.

8) Placement of an order for services constitutes the express agreement of the ordering party to all of the foregoing terms and conditions.