Request Service From ViaFact

SECURE REQUESTS: All forms below utilize our secure, HPAA-compliant e-signature service from SignNow. If online requests are out of your comfort zone, please feel free to contact ViaFact through our “Contact” tab, by phone, or through e-mail.
Please note these requests do not constitute a signed agreement to perform service. ViaFact will contact you for agreement and billing purposes upon receipt of your request. All submitted information will remain confidential.

Request for Service: Please complete the information provided in the following link; you may describe your request in the comment section, or wait until contacted by a ViaFact representative.  Healthcare agencies; please skip to the “Healthcare Agencies” section.

Client Information

Subject Information: Please complete this form if you are requesting information on an individual.  All Clients must also complete the “Client Information” link above.

Subject Information

Healthcare Agencies: Please send both a patient referral and HIPAA disclosure to request service.

Patient Referral

HIPAA Disclosure

…or click to download our requests and send via e-mail to

ViaFact Patient Information Referral

HIPAA Privacy Authorization Form