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PDA

Pharmaceutical Diagnostic Analysis (PDA) Referral Form

(Required fields are highlighted yellow)

Your Information
First Name:
Last Name:
Company Name:
Company City:
Phone:	(example: 123-456-7890)
Email Address:
Claimant Information
File / Claim Number:
First Name:
Last Name:
Alias First Name:
Alias Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:	(example: 123-456-7890)
Date of Birth:	(example: 01-02-2005)
Social Security Number:	(example: 123-45-6789)
Gender:	M F
PDA employs exacting security measures in the storage and transmission of data to maintain strict adherence with all privacy and confidentiality regulations governing protected health information including the Graham Leach Bliley Act (GLBA) and the Health Insurance Portability and Accountability Act (HIPAA). By submitting a PDA referral, client represents that they have secured and maintained a valid medical authorization from the individual for which the search is intended. Client also acknowledges that a signed copy of the medical authorization must be provided prior to our release of said information. Please fax your signed release attention PDA Coordinator at 781 396-5592 or email to pda@bmegateway.com
Please check here to acknowledge the above statement and agree to its terms.

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