Consultative Approach
People, Processes & Technology
Reporting
Business Office Outsourcing
Insurance Resolution
Third Party Liability
Early Out/Self Pay
Bad Debt
Medicaid Eligibility
Physician Billing & Collections
Performance Guarantee
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Workers Compensation Information
* = required fields
* Name
Address
City
State
Zip
*Telephone
Employment Information What is the name and address of the employer you were working for when the accident happened?
Date of injury or accident
Employer Name
Address
City
State
Who should we contact at your place of business?
Name
Phone
Do you know the name and address of the worker’s compensation insurance carrier?
Name
Address
If know, please provide a claim number
If know, please provide the name of your claims adjuster
Health insurance
Name of Health Insurance Company
Name of individual whose whole name is on the policy
Identification Number
Group Number
Attorney Information
Have you hired an attorney to help you in this matter?
Yes
No
If yes, please give name, address and phone:
Attorney Name
Attorney Address
Attorney City
Attorney State
Attorney Phone
