REPORT A CLAIM

Upon submission you will receive an acknowledgement email. Please do not place this completed form or the acknowledgement email in the patient’s medical chart. Keep all information related to this matter in a separate legal file.

Date of Report(Required)

Reporter Information

Please provide the required information for the individual reporting the matter (“Reporter”)

Reporter Name(Required)

Reporter Email(Required)

Reporter Phone(Required)

Reporter Company(Required)

Reason for Report(Required)

Insurance Information

Insured Name(Required)

Insured Policy Number(Required)

Insured Practice State(Required)

Insured Phone Number(Required)

If different from reporter above

Insured Preferred Email(Required)

To be used for all written communication

Patient/Claimant Information

Full Name(Required)

Patient Date of Birth(Required)

Date of Treatment Triggering This Report(Required)

File Upload

Please attach any claim related correspondence, legal documents and medical records related to this patient prior to submitting form. You will receive email confirmation upon our receipt of your submission.

File

Drop files here or

Max. file size: 64 MB.