Medical Cost Projection Order Form

1. Complete the MCP Order Form below.

2. Attach all imaging reports, treating doctor records, operative reports, surgical recommendations.

3. We will send you payment instructions, a services agreement to be signed, and treating doctor recommendation forms to be filled out and send back.

4. Once payment is received and all forms are returned, we will proceed with the evaluation.

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Please give us a call if you have any questions – 833-222-5293

Medical Cost Projection Order Form2

Service Details

Were X-rays Taken?
Where X-rays were taken
Were MRIs Taken?
Where MRIs were taken
Were Injections Given?
Were injections given?
Was Surgery Performed?
Was surgery performed?
Was Surgery Recommended
Was surgery recommended?

Service Details

Type of Service Ordered?
We secure venue, if needed
In San Antonio, TX

  • $1,250

Travel Outside of San Antonio, TX

  • $1,750

Expedited (contact us if this is required)

  • $2,750
Maximum upload size: 256MB