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Need Assistance: (800) 765-7510
Email: inhouse@datafied.com
Our Corporate Site: www.datafied.com


Your Privacy and Data Security is very important to Datafied, all of our transmissions are done using 128-bit encryption. We do not share any information with third parties, all data collected on this form is to verify patient's identity and payment information. For more information please contact us.
Facility Information: Indicates Required Field
Physician/Facility Name:  
Address:
City: State:
    Zip:  
Contact Name:
Phone: Email:
Fax:

Request Information:
Average number of requests you receive in 1 month:
Out of these requests, how many are:
Insurance Requests:
Patient Requests:
Attorney Requests:
Doctor/Facility Requests:
Government Requests:

Copy Information:
Do you require a copy fee? If so, what is the fee?
If there is a copy fee, is this fee waived for patient/government requests?  
Do you want a set copy day and time? 
If so, what would be the copy day and time?  
Does your facility have an off-site storage facility?  
How did you hear about us? 
Would we be your exclusive copy service?