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Subpoena Request

Schedule a Deposition

Video Teleconference

Authorization: Disclose Health Info

Request of Multiple Records

Online Forms: Additional Providers

We offer almost all of our forms online for your convienence.

Please note: Tackla & Associates confirms all jobs by telephone 24 hours prior to its commencement. If you do not receive a phone call from us, WE DO NOT HAVE YOUR JOB SCHEDULED. Toll Free (800) 871-0861 :: Office (216) 241-3918
Additional Providers form
2.additional Provider Number:
Records wanted (any/all)	Records XRays Billing Employment Video Audio
time frame: Date Start	Month: Day: Year:
time frame: Date End	Month: Day: Year:
other (please specify)
Special Instructions
Records Needed By	Month: Day: Year:
Phone
Fax Number
Name
Email Address
Address
City
State
Zip
3. additional Provider Number:
Records wanted (any/all)	Records XRays Billing Employment Video Audio
time frame: Date Start	Month: Day: Year:
time frame: Date End	Month: Day: Year:
other (please specify)
Special Instructions
Records Needed By	Month: Day: Year:
Phone
Fax Number
Name
Email Address
Address
City
State
Zip
4. additional Provider Number:
Records wanted (any/all)	Records XRays Billing Employment Video Audio
time frame: Date Start	Month: Day: Year:
time frame: Date End	Month: Day: Year:
other (please specify)
Special Instructions
Records Needed By	Month: Day: Year:
Phone
Fax Number
Name
Email Address
Address
City
State
Zip
requester info
Name
Phone
Fax Number
Email Address
Address
City
State
Zip

Please expect a call from us within 24 hours of filling out our form.