Submit a Funding Request
Requesting Party (Please fill out the form completely)
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Injured Party Information
First Name
Last Name
Date of Accident
Date of Birth
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Phone
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Address
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Requested Procedure Information
Treatment Requested
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Anesthesiology
Concussion/TBI Protocol
DME/Supplies
Follow up visit
Imaging
Initial Eval - MD
Initial Eval - Chiro
Injections
Ortho/Spine
Pain Mgt
Psychology/Psychiatry
PT
Surgery Center (Facility Fees Only)`
Surgery (Professional Fees Only)
Has your client received any medical treatment to date? (Check all that apply)
No Treatment to Date
Emergency Room
Imaging
Chiropractic
Ortho/spine
Psych
Pain Management
Urgent Care
PCP
Diagnosis/Symptoms
Provider or Facility Requested
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Fax
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Additional Notes
If you have trouble with this form or need to contact us directly:
scheduling@redrockdiagnostics.com
Phone: (833) 277-7625 / Fax: (702) 202-2052
Red Rock Diagnostics, LLC ∙ P.O. Box 26119 Las Vegas, NV 89126