INTEGRATED RISK SERVICES INC.

P.O. BOX 85 SYOSSET, NEW YORK 11791-0085 | TEL 516-682-0667 | FAX 516-682-0668

MRI & X-RAY FILM REVIEW REQUEST FORM

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Requestor

Law Firm / Company

Telephone & Fax Numbers

E-Mail Address

Your File Number Carrier File Number Assigned Attorney Date of Loss Plaintiff - Subject

Type of Films Number of Films Radiologist (Optional) Have Doctor: Draft Written Report Call Attorney Directly Other - See Instructions

Claims Examiner & Carrier Carrier's Full Address Special Instructions

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