Gambrell Health Services Medical Document Reviewers

Medical Case Review and Enhancement

WORK REQUEST

Fields marked with an * are required

Requester Information

Date

Who is requesting the medical record review? *

Company / Organization

Company's Name

Point of Contact Name

Business Manager's Name

Business Manager Phone Number

Business Manager's Email

Your Information

First Name

Last Name

Email *

Confirm Email *

Phone *

Address

Address *

City *

State *

Zip *

Type of Work Product Requested

Type of Work Product Requested, Please Specify and Use the Checklist Below *

Checkbox List *

SORTING and CATEGORIZING MEDICAL RECORDSPRE-EXISTING CONDITIONSMEDICAL RECORDS CHRONOLOGIESMEDICAL RECORDS SUMMARYKEY POINTS and ANALYSISMEDICAL RESEARCHIDENTIFY MISSING RECORDSINDEPENDENT REVIEWWORKERS COMPENSATIONPERSONAL INJURYLIFE-CARE PLANNINGMEDICAL NEGLIGENCEBIRTH INJURYWRONGFUL DEATHNURSING HOMEELDER ABUSE

Other, Not on List — Please Describe

Logistics

Medical Record Page Count and File Size *

Time Table — When You Need Work Returned *