Page 1 of 2 NSS FEE SCHEDULE FOR MEDICAL RECORDS & BILLING LEDGERS Credit Card Payment Required For Billing Ledgers: • Billing Ledgers (Updated Patient Ledger requiring “special processing” per Arizona Revised Statutes 12-351) $35.00 • Expedited Service for Production of Documents as Requested (Same Day Service) $25.00 • Notarized Affidavit of Custodian of Records (As requested for Billing Records) $55.00 • Signed Certificate of Records (Non-notarized for Billing Records) $25.00 You Will Be Invoiced For Medical Records: • Clerical Costs for Production of Requested Documents ($10.00 an hour per Arizona Revised Statutes 12-351) Per hour charge • Medical Chart Reproduction ($.10 a page per Arizona Revised Statutes 12-351) Per page charge • Expedited Service for Production of Documents as Requested (Same Day Service) $25.00 • Notarized Affidavit of Custodian of Records (As requested for Medical Records) $55.00 • Signed Certificate of Records (Non-notarized for Medical Records) $25.00 © 2014 Negotiated Settlement Solutions, LLC - All Rights Reserved FS 012014 NEGOTIATED SETTLEMENT SOLUTIONS, LLC, 4400 North Scottsdale Road, #286, Scottsdale, Arizona 85251 Tel. 480-725-9300 • Fax 480-275-2526 • www.nss-llc.net Page 2 of 2 RECORD and/or BILLING LEDGER REQUESTS Please enter complete and accurate information. Fax completed form to 480-275-2526 or email to: [email protected] By submitting this form, you agree to the Fee Schedule on page 1. SUBMITTER INFORMATION Attorney/Insurance Co. Name: Submitter Name: Submittal Date: Telephone Number: FAX Number: Email Address: PATIENT INFORMATION Patient Name: Patient Street Address: City: Date of Birth: Healthcare Provider: State: Zip Code: SSN: Date of Accident: ADDITIONAL INFORMATION © 2014 Negotiated Settlement Solutions, LLC - All Rights Reserved RBR 022014 NEGOTIATED SETTLEMENT SOLUTIONS, LLC, 4400 North Scottsdale Road, #286, Scottsdale, Arizona 85251 Tel. 480-725-9300 • Fax 480-275-2526 • www.nss-llc.net