Medical Care Coordination Intake Form

Medical Care Coordination Intake Form

Contact concierge@mylegalstream.com for any questions or call (866) 580-0869.
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Accident / Injury*

MonthDayYear
Date
Client Phone Number*
Please enter a valid phone number.
Client Email (optional)
example@example.com
Insurance (if applicable):
ex. Medicare, Medicaid, BCBS, etc.
Language*
Gender
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Need to add another client for this case? Include Name, DOB, Phone & Address if different than above for each)
Attorney Name*
Please include First & Last name
Law Firm Name*
Case Manager Name*
Point of Contact for Attorney / Firm
Attorney Phone*
Please enter a valid phone number.
Case Manager Email*
example@example.com
Has Liability been Accepted?*
*If No, Please explain
Insurance Company Name & Type*
ex: UM, UIM, 3rd Party, Subscriber/Non-Subscriber, etc
Policy Limits*
*If unavailable, please type "unavailable". If limits not yet identified, please provide when available
Case Type
Healthcare specialty client should see initially*
ex. Primary Care (MD), Pain Management (MD) Neurology (MD), Ortho (MD), Chiro, PT, etc.
Please list any previous providers, facilities or services if any (i.e. Hospital / ER, PCP, Imaging, etc). You can also include any relevant notes for our team here*
*If none please indicate NONE or N/A
Is there a police report?*
*If Yes, Please upload police report below
Please upload any relevant records (Medical, Imaging, Police Report, Policy, etc)

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Does your client need any pre-settlement funding? (Yes, we offer that!)
LegalStream Marketing/Sales Representative*
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