Language
English (US)
Español
Patient Claim Information
Please supply the requested information in this HIPAA Compliant Form.
Patient Name
Patient Date of Birth
Patient Guardian (if a minor)
Patient Address 1
Patient Address 2
Patient Phone Number
Patient Email
Date of Service
Account Number
Where was medical care received?
Your Attorney's Information
If you have appointed an attorney, please provide their contact information and then hit the "Submit Information" button at the bottom of this page.
Attorney Name
Attorney Phone Number
Injury Information
Was your injury caused by someone else?
Yes
No
This injury was caused by:
An accident where I was at fault.
An accident where I was NOT at fault.
An accident where I was a passenger.
Something other than a motor vehicle accident.
Please enter date and location where the injury was sustained.
Please provide additional details about the accident including which police department responded.
Patient's Health Insurance Information
Does the patient have health insurance?
Yes
No
Enter the Insurance Carrier
Aetna, Amerigroup, BCBS, etc.
Health Insurance Group Number
Health Insurance Policy Number
Patient's Auto Insurance Information
Has a claim been filed with Patient's Automobile Insurance or will there be?
Yes (please provide claim information)
No, and I do NOT intend to file a claim.
No, but I WILL file a claim.
Enter Patient's Auto Insurer Name
Progressive, State Farm, USAA, etc.
Patient's Policy Number
Patient's Auto Claim Number
Insurance Adjuster Name
Insurance Adjuster Phone
At-Fault Party Auto Insurance Information
Has a claim been filed with At-Fault Party's Automobile Insurance?
Yes (please provide claim information)
No, and I do NOT intend to file a claim.
No, but I DO intend to file a claim.
At-Fault Auto Insurer Name
Progressive, State Farm, USAA, etc.
At-Fault Policy Number
At-Fault Auto Claim Number
At-Fault Adjuster Name
At-Fault Adjuster Phone
Workers Compensation Information
Enter information here if your injury was sustained on the job.
Were you at work during the accident?
Yes (please provide employer information)
No
Employer Name
Employer Phone
Workers Comp Insurer
Workers Comp Claim Number
The information I have provided is true and correct, and I authorize its use by O'Brien & Feiler, and understand that no representative relationship is created by using this form.
*
I agree
Please enter the word to the right.
*
Submit Information
Clear Form
Should be Empty: