Kimberly Ward

  ciox 
 Fee Approval Request 
 HEALTH 
 CIOX HEALTH 
 Please deliver this to the following medical record requester: 
 Attention : 
 Facility: 
 Silverlake Medical Center 
 Requester : 
 TScan 
 Site : 
 20331 
 Address : 
 8458 Theresa Curve Apt. 978
Klineport, VI 47154 
 Address : 
 8458 Theresa Curve Apt. 978
Klineport, VI 47154 
 City, State, 
 City, State, 
 Zip : 
 Seattle, WA 98199 
 Zip 
 Detroit, MI 48201 
 Rep 
 Telephone : 
 719-456-3302 
 CIOX Rep: 
 Vernette Gordon 
 #: 
 825121 
 Fax : 
 844-102-9434 
 Fax to: 
 Records 
 CIOX HEALTH REP Vernette Gordon 
 Fax Number: 313-993-0763 
 Phone: 313-745-3021 
 Dear Medical Record Requester : 
 Date: 01/2023/19 
 CIOX HEALTH has contracted with Silverlake Medical Center (Medical Facility/State) to copy 
 it's authorized requests for medical records.
 03/28/2019 
 Patient : 
 Kimberly Ward 
 birthdate : 
 09/1990/01 
 Soc. Sec. # : 
 service date
 11/2015/04
 CIOX HEALTH Fee Schedule 
 FOR MEDICAL RECORD REQUESTER USE ONLY 
 In order for your request to be processed you will need to complete the five items inside this box. 
 Approved 
 Date: 
 By: 
 Hamal 
 j 
 11/2018/12 
 (Signature) 
 Print Name: 
 Phone: 
 Hannah Reifler 
 206-812-6911 
 Title: 
 Assistant Records Retrieval Specialist 
 MUST BE COMPLETED TO PROCESS REQUEST 
 Template Revision: 3.10.16
