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Personal Injury

Provider Information Form 

New Provider Details

If treatment is ongoing, skip and update our office when the end date is known or predicted by your doctor.

E.g., ER / Urgent Care, Primary Care, Imaging (MRI/CT/X-ray), Physical Therapy, Chiropractic, Pain Management, Mental Health, Counseling, Pharmacy

Billing Information

If unknown, state estimated amount (e.g., "est. $3,000") or "unknown."

If unknown, state estimated amount (e.g., "est. $3,000") or "unknown."

Health insurance used?
Yes
No
Are there outstanding balances?
Yes
No
Has any provider asserted a lien or subrogation interest?
Yes
No

Treatment Status

Are you still treating with this provider?
Yes
No
Were future visits recommended by this provider?
Yes
No
Has this provider indicated any permanency?
Yes
No

📌 Important: Please complete a separate form for each medical provider listed on your Medical Provider List.

 

It is important that you keep this information updated. If you begin treatment with a new provider, promptly update your Medical Provider List and complete a new provider form. This ensures we can obtain all related records and pursue maximum recovery on your behalf.

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