Billing Ledgers and Medical Records Request

STEP#1

Select the item/items that you are requesting

Medical Records $70.00
(Does not include billing ledgers)

Billing Ledger $75.00
(Updated Patient Ledger requiring "special processing" per Arizona Revised Statutes 12-351)

Notarized Affidavit of Custodian of Records $85.00
(As requested for Billing Records)

Signed Certificate of Records $60.00
(Non-notarized for Billing Records)

* Note (All charges include the credit card processing fees)
To pay Lien Settlements or any other charge not listed above by credit card contact us at: 480-725-9300 or Support@nss-llc.net

STEP#2

All Information is Required

Submitter Information

INVOICE # LR No Invoice Number? Give us a call! Please fill in the field

Attorney/Insurance Co. Name

Submitter Name Please fill in the field

Submittal Date Please fill in the field

Email Address Please fill in the field

Fax Number Please fill in the field

Patient Information

Patient Name Please fill in the field

Date of Birth Please fill in the field

Date of Accident Please fill in the field

Medical Provider Please fill in the field

Additional Notes

STEP#3

Payment Processing

Card Number

Expiration

CVC

PUSH ONLY ONCE