PIP Authorization Form

Personal Injury Protection Coverage (PIP) Authorization Form
Dear Patient,

You have indicated to us that you were involved in an automobile accident. As a courtesy to you, we will file for benefits under your Personal Injury Protection Coverage (PIP), so a2z Physical Therapy can be reimbursed for today's services. Even if someone else is at fault, you may use your PIP coverage for these expenses. Using your PIP coverage will not increase your auto insurance premium. Please note that in the event your insurance carrier requires copies of your medical records to process your claim, a2z Physical Therapy will provide all necessary documents at no additional cost to you. Once PIP benefits are exhausted, it is your responsibility to obtain a letter from your PIP carrier indicating there are no further benefits available BEFORE we can begin filing for services rendered to your attorney under a medical lien.
Automobile Insurance Company Name
Address
Phone Number
Agent's Name and Address if different from above
Claim Number
Policy Number
Date of Accident*

MonthDayYear
Date
Location
Driver's Name at the Time of Accident
Name*

First NameLast Name
I authorize a2z Physical Therapy to apply for benefits on my behalf for all services rendered. I further authorize the release of all medical information necessary to process my claims. I request that payment be made directly to a2z Physical Therapy. I permit a copy of this authorization to be used in place of the original. If it is necessary to turn this account over to a collections agency/attorney, I agree to pay all reasonable costs of collections, attorney's fees.
Signature of Patient or Legal Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty: