Enter #:

What's This?

Dupuytren's Clinic Product Recommendations Patient Education Patient Education Patient Education Patient Education
Access Request



 

Access Request

 

 

To obtain access to your Work Comp Patient Folders,

 

please complete the form below.


 FORM INSTRUCTIONS:

Please read these instrucitons to request access to your section.

First Name          

Self Explanatory

required 
Last Name

Self Explanatory 

required
Practice / Hospital / Organization
Please list your company name
required to verify identity
Address

Claims Adjuster/
Nurse Case Manager  - office address    

required to verify identity
Home phone        

provide your fax number instead

 
Work phone

use your work phone

 
Cell phone
you will receive a call from my cell to put in your address list

 
I am a:

select claims adjuster (please select this even if you are a nurse case manager)

 
I want to:     

select "Access Medical Professionals Section" 

 
Email          

needed to send your access code 

 
Describe your conditon, ask a question, provide other important information     
If you would like to choose your username and password please enter it in this box. Please make your pasword at least 6 characters long and include both letters and numbers.
 

REQUEST ACCESS

 
 
Enter the validation code
Enter the validation code here:
 

Please note: We will not be able to respond to emails regarding personal health issues and cannot give medical advice without an examination. If you have an urgent need please call our office 702.433.9533, DO NOT use this contact form.



© Grabow Hand to Shoulder Center.