Complete the following information and click submit to send us this information. After you click submit, you will receive a confirmation of this information by email. We will contact you shortly.

Note: Fields marked with a red asterisk ( * ) are required for processing.

Agent Information
Agent Name *		Phone *
Agent Number		Fax
Agency Name *
Agency Street Address
Agency City		State			Zip
Agency Phone *		Agency Fax
Email Address * Confirmation will be sent here.
Client Information
First Name *		MI		Last Name*
SS Number *
Date of Birth *		Age
Sex: *	Male Female
Client Insurance Information
Type of Insurance	-=Select One=- Life Health Disability LTC
Amount of Insurance		Policy Number
Insurance Company *
Name of Person Ordering this APS *		Phone *
Special Instruction:
Physician Information
Physician/Facility Name *
Contact Person
Street Address
City		State		Zip
Phone *
I understand that to complete this APS request, I must also fax NMS a copy of the “authorization to release medical records” to 561-967-9718.
If you have questions or concerns regarding this order, please call 800-269-0502.