Initial RequestFollow Up Request

Requesting Party Information ( Please fill out form completely )

Attorney Information

Please upload the Patient-signed Red Rock Lien or LOP and Health Insurance Waiver.

Maximum upload file limit is 25MB

 

SUBMIT FORM VIA EMAIL OR FAX TO:

preauth@redrockdiagnostics.com

Fax: (702) 463-4259

Questions? Call us at (877) 362-6077

Red Rock Diagnostics, LLC ∙ P.O. Box 26119 Las Vegas, NV 89126