Shiloh Chiropractic Motor Vehicle Accident Questionnaire Page 4
ADVERTISEMENT
1
2
3
4SHILOH CHIROPRACTIC MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
PAGE 3 of 3
INSURANCE DETAILS
This will help us organize things so YOU DON’T HAVE TO WORRY about filing and other things that can be confusing and
difficult for patients! This has to be filled out by the second visit so that we can bill the appropriate party rather than
you. When an accident occurs and when insurance companies and (possibly) attorneys are involved, things can become
complex. This helps us sort through the mess to make sure the appropriate notifications are sent out to minimize risk of
billing errors. Also, bring in a copy of your regular health insurance card(s). In rare cases, we may bill regular health
insurance as opposed to auto insurance, but that’s rare.
YOUR AUTO INSURANCE (Or the person with whom you were riding)
Insurance Company
______________________________________________________________________________
Address
______________________________________________________________________________
City/State/Zip
______________________________________________________________________________
Phone & Fax
______________________________________________________________________________
Claim #
______________________________________________________________________________
Policy #
______________________________________________________________________________
Contact Name
______________________________________________________________________________
OTHER PARTY’S INSURANCE COMPANY
Insurance Company
______________________________________________________________________________
Address
______________________________________________________________________________
City/State/Zip
______________________________________________________________________________
Phone & Fax
______________________________________________________________________________
Claim #
______________________________________________________________________________
Policy #
______________________________________________________________________________
Contact Name
______________________________________________________________________________
YOUR ATTORNEY (If you have retained an attorney, fill this out. If you don’t have one and we think you need one, we
will provide you with contact information for three attorneys who deal in Personal Injury. Not all accident cases require
an attorney especially if you fill this out because insurance companies will work with us easier!)
Name & Firm
______________________________________________________________________________
Address
______________________________________________________________________________
City/State/Zip
______________________________________________________________________________
Phone & Fax
______________________________________________________________________________
mva_questionnaire.doc
rev 07/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business