Priority Request

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


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

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