MEDISERV LTD. REQUIRES THE FOLLOWING INFORMATION IN ORDER TO PROCESS YOUR REQUEST FOR BILLING RECORDS:

WE DO NOT PROCESS FAXED REQUESTS.
WE DO NOT FAX RESPONSES

■ Patient name
■ Patient date of birth
■ Last 4 digits of Patient’s SSN
■ Name of Guardian if Patient is a minor
■ Account number (alpha and numeric)
Account numbers are required for records that are older than 2 years
■ Date of Service
■ Facility where service was rendered
■ HIPAA compliant Medical Release Form signed by patient or patient’s guardian
■ Affidavit/Subpoena must reflect physician group name.
We do not provide affidavits.
■ Self addressed stamped envelope (allow for 4-5 billing documents)

Check for prepayment made out to MEDISERV with patient’s name referenced

■ $25.00 fee per patient for billing records/affidavit (excluding Florida)
■ $50.00 fee per patient or deposition
■ $15.00 fee for corrected Affidavit or for affidavit not sent with initial request (excluding Florida)
■ $10.00 Notary fee for affidavit (Florida only)
(must include copies of original documents)

MAIL ALL REQUESTS TO:
ATTN: ATTORNEY REQUESTS
PO BOX 8549, FORT WORTH, TX 76124