New Case Intake Form
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1New Case Intake Form
Date of Request _______/_________/__________
So that Precision may begin processing your file immediately, please submit this completed form, along with any/all additional authorization forms to
Nature of Injury
Attorney Information
Name
DOI_______/_________/__________ DOD (if applicable) ______/_________/__________
Pho
ne ___________________________________ Fax _____________________________________
Specific Nature of
_________________________________________________________________
Accepted Injuries
Firm
Address _____________________________________________________________________________
City ________________________________________State _____________ Zip __________________
Attorney Email ___________________________________________
Yes
No
Still Treating
Last Treatment Date ______/_________/________
Paralegal/Associate Contact __________________________________________
Known Pre-Existing
Conditions
Paralegal/Associate Email
___________________________________________
Claimant Information
Nature of Claim
(check all that apply)
Name
Gender
Female
Male
Motor Vehicle Accident
SSN ____________________________________ DOB ________/____________/_________
No Fault Policy?
Yes
No
Address _____________________________________________________________________
No Fault Carrier
Full & Proper Name
City _______________________________________State _____________ Zip ___________________
Phone _______________________________________________________________________________
Might APIP be Obligated to Pay Medicals?
Yes
No
Has claimant lived in another state since date of injury?
Yes*
No
APIP Carrier
Full & Proper Name
*If yes, what state(s)? ________________________________________________________________
Policy Limit $_______________________________________________________
Settlement Information
Exposure ________________________________
Medical Malpractice
Has this case settled?
Yes
No
Nursing Home Negligence
Product Liability _________________________
Settlement Amount $________________________
Slip & Fall
Other_____________________________________
Settlement/Anticipated Settlement Date __________/_____________/______________
Liability Carrier
Comments
Full & Proper Name
Policy Limit $_______________________________________________________
WC Carrier
Full & Proper Name
Policy Limit $_______________________________________________________
OTHER BENEFITS
Start _______/_______/_____
Start _______/_______/_____
Start _______/_______/_____
Social Security Disability Insurance
Supplemental Security Income
Other _____________________________
RECEIVED
End _______/_______/_____
End _______/_______/_____
End _______/_______/_____
Relevant Claim Information
Claimant
Services Requested
Case Reported
Receiving
Please submit a copy of any/all correspondences with agency and claimant’s insurance cards
to Agency
Check all that Apply
along with this and all other authorization forms to
(Past or Present)
Medicare Conditional
HIC # ______________________________________________ Entitlement Date ______/_________/__________
Payment (Parts A/B )
Medicare Advantage
Insurance Company Name _________________________________ Group/ID # _________________________________
(Parts C/D)
Medicaid
Medicaid # _________________________________________ State(s) _______________________________________
Insurance Company Name ___________________________________________________________________________
Plan Docs Requested?
Self-Funded ERISA or
Group/ID # ___________________________________________
Other Private Healthcare
If Employer-based Health Plan, specify employer name _______________________________________________
Yes
No
Please provide Plan Document or Summary Plan Description if available.
TRICARE
Treatment Facilities ________________________________________________ Sponsor SSN_____________________________________
Veteran’s Administration
Treatment Facilities ________________________________________________ Sponsor SSN_____________________________________
Additional Comments
Liability
Workers’ Compensation
Medicare Set-Aside
Please forward the following documents for MSA Services:
Date of Medicare Eligibility______/________/_________
Allocation
Past 2 Years of Records/Reports from Claimant’s Treating Physicians
Past 3 Years of Payment History or Medical Benefits
HIC#_____________________________
Liability
Workers’ Compensation
Medicare Set-Aside
Past 3 Years of IME Reports
Opinion Letter
Bill of Particulars
Precision Resolution, LLC 3686 Seneca Street, Buffalo, NY 14224 (T) 888-961-LIEN (F) 716-712-0400 (E)
Intake document database found at
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