Order Form

Please fill out the form below to request records. If you would prefer to fill out a paper form, please download T-Scan's order form and mail it or fax it to us at 800-238-7307. We'll assign you an Account Specialist immediately in order to ensure your request is handled quickly and professionally.

* - required fields

Ordering Contact Information *Name *E-mail Address *Phone Number

Shipping Information Adjustor Name Phone Firm Name Attorney Name Attorney E-mail Paralegal Name Phone Number Fax Number Address City Zip Code

Billing Information

Billing information is the same as shipping information.

Name Phone Address City Zip Code

Claimant Information Claimant Name SSN Date of Birth

Case Name Case Number Claim Number

Contact Name Contact Phone Contact Fax Contact Address Contact City Zip Code

Expedite Return? Yes No

Record Providers

Name Address City Zip Code Phone Number Fax Number Date Range
Name Address City Zip Code Phone Number Fax Number Date Range
Name Address City Zip Code Phone Number Fax Number Date Range
Name Address City Zip Code Phone Number Fax Number Date Range
Name Address City Zip Code Phone Number Fax Number Date Range
Name Address City Zip Code Phone Number Fax Number Date Range
Name Address City Zip Code Phone Number Fax Number Date Range
Name Address City Zip Code Phone Number Fax Number Date Range

Additional Recipients

Name Address City Zip Code Phone Number Fax Number
Name Address City Zip Code Phone Number Fax Number
Name Address City Zip Code Phone Number Fax Number
Name Address City Zip Code Phone Number Fax Number
Name Address City Zip Code Phone Number Fax Number
Name Address City Zip Code Phone Number Fax Number
Name Address City Zip Code Phone Number Fax Number
Name Address City Zip Code Phone Number Fax Number

Attach Documents File 1: File 2: File 3: File 4: File 5:

4200 23rd Avenue W, Seattle, WA 98199 | Phone: 800-285-1507 | Fax: 800-238-7307