Purchase Request

Please complete the following form to request purchase of accounts receivable. Multiple treatment types can be selected in one submission, such as 1. Surgery Center (facility fees only), 2. Anesthesia, 3. Ortho/Spine.

Step 1: Fill out the form below to include cost estimate.
Step 2: Attach the clinical notes and Red Rock intake form from initial patient visit, if applicable.
Step 3: Submit

Healthcare Services Needed

Is this your first request for this account?

YesNo

Please attach Red Rock Intake Form:

Please attach clinical/progress note from initial consult.

Is this request for:

In Office ServicesOutside Referral - Services/Procedures with Another Provider

Please attach signed physician script.

Type of Care Recommended

Initial Date of Service

Next Appt. Date

CPT Coding for Procedure or DME

Please list each CPT code, separated by comma (Ex: 92014, 72141)

Cost

Please list cost for each CPT code, separated by comma (Ex: $289.00, $1,521.00)

Description of Procedure/DME Product

Additional # of Visits Recommended

Total Procedure/Product Cost

Total # of Visits Completed

Additional Notes

Requesting Facility Information (Please fill out the form completely)

Your Facility Name

Your Name

Phone

Fax

State

Injured Party (PATIENT)

First Name

Last Name

Date of Accident

Date of Birth

Phone

Cell Phone

State

Zip Code

Attorney Information

Firm Name

Contact at Firm

Phone

Fax

State

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

Purchaserequests@solutionsredrock.com

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

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

Contact Information