Cnyfamilycare - Auto Claims Form

NO FAULT INFORMATION REQUEST
The physicians at CNY Family Care do NOT participate with any auto carriers. As a qourtesy to our patients, we will bill your Insurance company. YOU will be responsibble to follow up with your insurance company and you will also receive bills just to let you know what is going on with your auto carrier with regard to your office visits.

Please fill out this form and return it to us with all the information requested, and we will be happy to provide your insurance company with the proper billing form.
Patient Name
Policy Holder's Name
Insurance Company Name
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Accident

MonthDayYear
Date
Claim Number (if known)
Insurance Phone Number
Please enter a valid phone number.
Contact Person's Name
Should be Empty:

NO FAULT INFORMATION REQUEST