PROMEDICAL - Patient MVA Form

We're sorry about your automobile accident. Please complete the requested information below so we can help process your medical claims as quickly as possible. (* = required entry)
Patient Name*

First NameLast Name
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address*
example@example.com
Can ProMedical contact you by SMS text message to verify insurance information related to your accident claim, (message/data rates may apply)?*

YesNo
Can ProMedical contact you by email to verify insurance information related to your accident claim?*

YesNo
Our File Number
Example: 1234567 (Leave blank if not known or not assigned)
Name of Medical Provider where you were treated*
Example: ABC Hospital
Date of Accident/Injury

MonthDayYear
Date
Was your injury or medical services related to an accident?*

YesNo
Select the option that best describes the accident:*

Single vehicle accidentMultiple vehicle accidentPublic Transportation accident (bus, train)Ride sharing or Taxi serviceMotorcycleWork-related auto accidentOther
Select ALL that apply to your accident:*

I have Automobile Insurance coverageI DO NOT have Automobile Insurance, but someone in my household doesI have optional MedPay coverage through my Automobile InsuranceI have hired an Attorney for this accidentI have health insurance coverage
Was your employer notified of this accident?*

YesNoThis was not a work related injury
Name of your Employer*
Contact Person your Employer*
Your Employer's Address

Street Address

CityState

Zip Code
Employer's Telephone Number
Format: (000) 000-0000.
Was your employer's insurance company notified of this accident?*

YesNoNot Sure
Your employer's Worker's Compensation name (at the time of the accident)
Workers' Compensation Insurance at the time of the accident, e.g. Liberty Mutual
Workers' Compensation Insurance Address

Street Address

CityState

Zip Code
Workers Comp Ins Adjuster Name
Workers Comp Ins Claim Number
Automobile Insurance Company name (at the time of the accident)*
Automobile Insurance at the time of the accident, example: Liberty Mutual
Automobile Insurance Address

Street Address

CityState

Zip Code
Automobile Ins Adjuster Name
Automobile Ins Claim Number
Please describe the circumstances related to your accident:
example: This was a slip and fall at ABC Store, etc.
Do you have Health Insurance?*

YesNo
Signature of Patient or Guarantor - Not Accident Related and No Health Insurance Available - Please be advised that on the date of the above referenced accident, I did not have any health insurance benefits available to me, either through my own policy or a policy of a household member.
Your Health Insurance Company Name*
Example: Blue Cross
Health Insurance Member ID
Health Insurance Policy Holder Name
Name of the person who is the primary policy holder
Health Insurance Group Number
Signature of Patient or Guarantor - I certify that the medical services related to this date of service was not related to a motor vehicle accident or injury. Please bill the health insurance as listed above.
Your Attorney's Name or Law Firm*
Your Attorney’s Address

Street Address

CityState

Zip Code
Telephone number of your attorney
Format: (000) 000-0000.
Should be Empty: