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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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!)
Do you anticipate this client may need a mini life care plan or full life care plan after treatment?
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