Injury Intake Form

Injury Intake Form

Please complete all data fields in the form below to streamline your request.

Injured Party Information

Apt., Suite, or Unit #

Cell or Home Phone #*

Phone

Incident Information

Body Part(s) Injured*

Please specify which body part(s) was injured.

(e.g. Left forearm, left wrist, lower back and neck)

Diagnostic Imaging*

Did you get an MRI or X-ray pursuant to your injuries?

Yes

Name of Facility

Please provide the name of the facility where you received diagnostic imaging.

Responsible Party at Fault*

Other party at fault

I am at fault

Injured Party*

Which of the following represents the injured party?

Driver

Passenger

Pedestrian

Vehicles Involved

Select the total number of cars involved in the accident

Select

Auto Personal Injury Protection (PIP)

Relation to Patient*

Select

Insurance Billing Address*

This information may be listed on the back of your card, online or provided to you by your adjuster.

Policy #*

Located on your insurance card.

Claim #*

This information is provided by your adjuster or insurance company

Adjuster’s Full Name*

Adjusters Phone #*

Phone

Adjusters Fax #

Phone

Is Your PIP Exhausted?*

An exhausted PIP means the insurance company has satisfied the policies coverage limit.

Yes

Unknown

PIP Coverage

What is your policy coverage limit?

Health Insurance Information

Please provide your personal health insurance information

Primary or Secondary Insurance*

Primary Only

Primary and Secondary

Primary Insurance Information

Insurance Company Name*

Insurance Phone #*

Phone

Insurance Billing Address*

Subscriber Name*

The main policy holder listed on your insurance card

Subscriber ID*

This can be found on your insurance card

Group #*

This can be found on your insurance card

Relation to Patient*

Select

Secondary Insurance Information

Insurance Company Name*

Insurance Phone #*

Phone

Insurance Billing Address*

Subscriber Name*

The main policy holder listed on your insurance card

Subscriber ID*

This can be found on your insurance card

Group #*

This can be found on your insurance card

Relation to Patient*

Select

Attorney Information

Attorney Hired*

Did you hire an attorney for your injury case?

Yes

Legal Asst/Paralegal Full Name

Upload Medical Records & Imaging Diagnostic

If applicable, please upload all medical records pertaining to your accident (upload each document package separately; i.e. 1) Medical Records 2) Diagnostic Imaging Report).

Drag and drop files here or

Additional Comments

Please provide any additional comments that may assist in further accommodating your request.

Send me a copy of my responses