PERSONAL INJURY - PIP

PERSONAL INJURY - PIP

PERSONAL INJURY - PIP
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

A. Reporting to Attorney

Which information would like to receive monthly and how do you prefer to receive information? Check all that apply
copies of billingmonthly statementsSOAP chartsProgress reportsOther
faxmail (US POSTAL SERVICE)emailupon requies

B. Primary Insurance Coverage
Insured
Insurance ID #
Insurance Carrier
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Adjuster Name

First NameLast Name
Adjuster Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Adjuster Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
PIP Policy Amount $
Date of coverage

MonthDayYear
Date
Date of termination of coverage

MonthDayYear
Date
PIP available $

D. Client Information
YesNo
Please describe how you felt immediately after the accident.

E. Treatment
YesNo
MRI 1X-RayCT-ScanNo
Immediately after the accidentThe next day2 or more day later
Diagnosis
Treatment received

H. General Understanding
I understand that Orthopedic Massage Therapy and other realted health care services from this office are not in anyway to be used instead of or in place on consulting a Physician for diagnosis and treatment of any physical symptoms, but to be used in conjuction with, or on the advice, referral or prescription of my physician (s)
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