For Customers - Contact Us Questionnaire

Tell Us About Yourself

Please complete the following information then click the Submit Form button below. Please DO NOT include any HIPAA Electronic Protected Health Information (ePHI) e-mail communications in this request form. If you need to transmit ePHI, First Insight will direct you to a secure email site. If you do not receive an email from us confirming that we received your request, please call us at 800.920.1940. Thank you.

* Fields marked with an asterisk are mandatory.

Your Name (first, last)*:

Doctor’s Name:

Practice*:

City*:

State/Province*:

Email Address*:

Phone Number*:

Technical Support Categories:

Please rate the urgency of this request*:

	Call me within next business day.
	Call me to schedule an appointment.
	Email me an answer.

Detailed Description of Support Request*

# Any emails sent after 3:00 p.m. Pacific Time
will not be received until the next business day.
If you do not receive an email from us confirming that we received your request,
please call us at 800.920.1940. Thank you.