PROMEDICAL - Patient WC Form

We're sorry about your work-related 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

Date

Was your employer notified of this accident?*

YesNoThis was not a work related injury

Do you have Health Insurance?

YesNo

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.

Signature of Patient or Guarantor - 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.

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

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 accident was not a work related injury. Please bill the health insurance as listed above.

Have you hired an Attorney for this accident?

YesNo

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.