Scott Richardson

  ciox 
 Fee Approval Request 
 HEALTH 
 CIOX HEALTH 
 Please deliver this to the following medical record requester: 
 Attention : 
 Facility: 
 Downtown Medical Center 
 Requester : 
 TScan 
 Site : 
 64580 
 Address : 
 0257 Victoria Isle
West Sandy, FM 99490 
 Address : 
 0257 Victoria Isle
West Sandy, FM 99490 
 City, State, 
 City, State, 
 Zip : 
 Seattle, WA 98199 
 Zip 
 Detroit, MI 48201 
 Rep 
 Telephone : 
 374-592-9180 
 CIOX Rep: 
 Vernette Gordon 
 #: 
 825121 
 Fax : 
 294-441-1438 
 Fax to: 
 Records 
 CIOX HEALTH REP Vernette Gordon 
 Fax Number: 313-993-0763 
 Phone: 313-745-3021 
 Dear Medical Record Requester : 
 Date: 22-05-07 
 CIOX HEALTH has contracted with Downtown Medical Center (Medical Facility/State) to copy 
 it's authorized requests for medical records.
 03/28/2019 
 Patient name : 
 Scott Richardson 
 birth date : 
 03-10-21 
 Soc. Sec. # : 
 DATE OF SERVICE
 23-09-22
 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 
 18-08-17 
 (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
