Patient Claim Information

Patient Name

Patient Date of Birth

Patient Guardian (if a minor)

Patient Address 1

Patient Address 2

Patient Phone Number

Patient Email

Date of Service

Account Number

Where was medical care received?

Attorney Name

Attorney Phone Number

Was your injury caused by someone else?

This injury was caused by:

Please enter date and location where the injury was sustained.

Please provide additional details about the accident including which police department responded.

Does the patient have health insurance?

Enter the Insurance Carrier

Aetna, Amerigroup, BCBS, etc.

Health Insurance Group Number

Health Insurance Policy Number

Has a claim been filed with Patient's Automobile Insurance or will there be?

Enter Patient's Auto Insurer Name

Progressive, State Farm, USAA, etc.

Patient's Policy Number

Patient's Auto Claim Number

Insurance Adjuster Name

Insurance Adjuster Phone

Has a claim been filed with At-Fault Party's Automobile Insurance?

At-Fault Auto Insurer Name

Progressive, State Farm, USAA, etc.

At-Fault Policy Number

At-Fault Auto Claim Number

At-Fault Adjuster Name

At-Fault Adjuster Phone

Were you at work during the accident?

Employer Name

Employer Phone

Workers Comp Insurer

Workers Comp Claim Number

The information I have provided is true and correct, and I authorize its use by O'Brien & Feiler, and understand that no representative relationship is created by using this form.

Please enter the word to the right.

Patient Claim Information

Your Attorney's Information

Injury Information

Patient's Health Insurance Information

Patient's Auto Insurance Information

At-Fault Party Auto Insurance Information

Workers Compensation Information