Please provide as much information as possible when completing this injury report.
Auto Accident/Personal Injury Financial Policy
It is necessary for you to provide us with accurate and complete account/claim information. As a courtesy, we will submit charges to your insurance. Ultimately, you are responsible for all charges incurred on your account.
If you have health insurance benefits, you need to present your insurance card and a photocopy will be made and kept in your file for future submission once your med-pay limit on your auto insurance policy has been exhausted.
If we are submitting charges to your health insurance you will be expected to make payments according to the benefit information provided to our office. If you suspend or terminate care with our office, we reserve the right to request payment in full immediately regardless of any claims submitted. You will be expected to resolve your balance in full no more than 6 months after your doctor has discharged you from this case unless other arrangements have been made with our office.
If an attorney is representing you, please notify us immediately.
(Please fill out all information completely, indicate N/A if not applicable)
If yes, please answer the questions in the paragraph below.