Submit a Funding Request

Requesting Party (Please fill out the form completely)

Injured Party Information

Requested Procedure Information

A physician script attachment is required because the treatment requested is Imaging.

If you have trouble with this form or need to contact us directly:

Phone: (833) 277-7625 / Fax: (702) 202-2052

Red Rock Diagnostics, LLC ∙ P.O. Box 26119 Las Vegas, NV 89126