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Rush Service Request

Service Being Requested

Case Classification


Adjustor Information

Claimant

Claimant Case Information

Documentation Checklist

Please upload the following copies with this completed form:

  • Records/reports from Claimant’s treating physician or physicians from the last two (2) years of treatment
  • Print out of full payment history and full RX history
  • Copy of Claimant’s Medicare card, if available
  • Copy of any prior rated ages, if available
  • Relevant legal documents, if available

Please Note

The maximum file size limit for each individual file is 20MB

The total file size limit for all files uploaded at once is 2GB

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Please Note

The maximum file size limit for each individual file is 20MB

The total file size limit for all files uploaded at once is 2GB

If you require to upload any files larger than 20MB, please submit these files to this external Microsoft Form

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    Contact Us

    64 Danbury Road
    Suite 201
    Wilton
    CT 06897

    Tel: +1 267 857 0544

    For more information please email info@allankoba.com

    To refer a file please email referrals@allankoba.com