To save time, web portal submission and electronic document upload will allow you to track the status of your request and receive a quicker response.
Manual Non-Portal Submission
Download the WISeR intake form for Washington State requests.
- You may fill this interactive form in a PDF Reader/viewer, (like Adobe Acrobat Reader, or a built-in browser viewers that let you open, read, print, and fill forms).
- After filling the form, save in this format :WISeR-Intake-Form_Date_Name.pdf
- Then print
- Include form with supporting medical record documents for review.
- Send via mail or fax to:
| Fax: | (972) 823-9415 |
| Mail: | 6509 Windcrest Drive, Suite 165 Plano, TX 75024 |
This request document and medical record documentation is required and may be submitted via fax, mail or electronic portal. All fields are REQUIRED unless otherwise noted. Incomplete or illegible handwritten requests will be non-affirmed.