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APS Request
Complete the fields below and click on the"Submit APS Request" button on the bottom of the form. Your request will be processed within 2 hours of receipt weekdays between the hours of 8:00 a.m. and 5:00 p.m. (excluding holidays). You will receive an email confirmation of your request which can be used for tracking purposes.
 
APS Info:
Insurance Co.:
Physician/Hospital:
Street Address:
City:
State: (e.g. FL)
Zip Code: (e.g. 32257)
Physician Phone: (e.g. 904-733-2222)
Agent Name:
Agent email address: (required)
Applicant Info:
First Name:
Middle Initial:
Last Name:
Street Address:
City:
State: (e.g. FL)
Zip Code: (e.g. 32257)
DOB: (e.g. 08/18/1965)
Special Requirements:  All records for the past 5 years will be requested unless otherwise specified.  If you need a specific time period other than for the last 5 years, please advise us below.
Other Comments:
Click Box:

        

 


IMR Jacksonville
450-106 State Road 13, Suite 115
St. Johns, Florida 32259
Phone: (904) 733-2222
Fax: (904) 230-0091
Email: imrjax@imrjax.com