Personal Injury Verification Form
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1PERSONAL INJURY VERIFICATION FORM
Patient Acct#:
Section 1 - Patient Data
Date of Injury:
/
/
Primary Policyholder
Patient Name:_____________________________________________________
Name:_________________________________________________
Relationship to Primary Policyholder:
Self
-
Spouse
-
Child
-
Other (Describe__________________________)
Patient's SS#/ID#:____________________________________________________
Patient's DOB:
Section 2 - Primary Medical Coverage
Date Called:
/
/
Total Medical Limit Amount: $_________________________________
Amount Remaining: $________________________________
Claim #:____________________________________________
Has accident been reported?
Yes
-
No
-
Unsure
Will benefits be paid directly to doctor?
Yes
-
No
-
Unsure
If No - Will payment be payable to the
Has a medical file been opened?
Yes
-
No
-
Unsure
patient and mailed to Dr.'s office?
Yes
-
No
-
Unsure
Insured's Policy #:______________________________________________
Adjuster's Name:_________________________________________________
Insurance Co. Name:________________________________________________________
Insurance Co. Code:__________________________
Mailing Address:___________________________________________________________________________________________________
City, State & Zip:___________________________________________________________________________________________________
Phone #:_________________________________________
Person Spoke with:_____________________________________________________
Section 3 - Adverse Party Insurance Data
Date Called:
/
/
Responsible Party Name:____________________________________________
Insured's Claim #:_________________________________
Has accident been reported?
Yes
-
No
-
Unsure
Will benefits be paid directly to doctor?
Yes
-
No
-
Unsure
If No - Will payment be payable to the
Has a medical file been opened?
Yes
-
No
-
Unsure
patient and mailed to Dr.'s office?
Yes
-
No
-
Unsure
Insured's Policy #:______________________________________________
Adjuster's Name:_________________________________________________
Insurance Co. Name:________________________________________________________
Insurance Co. Code:__________________________
Mailing Address:___________________________________________________________________________________________________
City, State & Zip:___________________________________________________________________________________________________
Phone #:_________________________________________
Person Spoke with:_____________________________________________________
Section 4 - Patient's Attorney Data
Date Called:
/
/
Attorney's Name:____________________________________________________________
Contact Name:_______________________________
Mailing Address:___________________________________________________________________________________________________
City, State & Zip:___________________________________________________________________________________________________
Phone #:_________________________________________
Fax #:________________________________________
Will Attorney accept or honor a lien for account balance?
Does Attorney want copy of the patient's medical bills?
Yes
-
No
-
Unsure
Along the Way
-
When Patient is Released
-
Unsure
Date Lien Sent to Atty:
Date Lien Received from Atty:
PI Verification Form
(c) KMC University 2007
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Parent category: Medical