Immediate Response Needed

Patient Name: TESTCASE2006 DOE
Patient DOB: 11/20/1979
Request Type: Evidence Request
Request ID: 20140805172429_728058
Requesting Office: WI - Wisconsin DDS [S56]
Patient SSN: 2006
Provider Name:
Request Date: 03/30/2010
Disability Examiner: testExaminer

Request Details

Special Instructions:

MER REPORT Test for ERE Release

Documentation:

File Name Date Added
Request Letter 08/05/2014
Authorization To Disclose Information 08/05/2014
Background MER 08/05/2014
Supporting Documentation 08/05/2014

Request Response

Do you have records to submit for this case?

Add Reason

Reason for No Records to Submit:

(4,000 characters maximum)

Attach and Upload Files

  • A maximum of 25 files can be added and all files must total less than 200 MB
  • File types accepted: .wpd, .doc, .docx, .txt, .xls, .xlsx, .pdf, .rtf, .tiff, .tif
  • Please do not upload password-protected files because they cannot be processed.

Additional Information

(4,000 characters maximum)

Additional Examination or Test (Optional)

Is the provider willing to provide an additional examination or test?

Electronic Signature Agreement (Optional)

If you wish to generate an electronic signature, please read this statement and indicate your agreement by checking the "I have read and agree to the above" checkbox. When you select "Submit", you will generate an electronic signature and submit your response.

By checking the "I have read and to the above" checkbox below, I am certifying that I am the author of the uploaded document(s). The information I have uploaded is accurate and I am certifying that I have electronically signed the document(s) contained within.

User Resources