AUTO ACCIDENT FORM
First Name: Last Name: Date of Birth:
Street Address: City: State: ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Phone Number:
Date of the accident: br>
After the Accident
YesNo If yes, where:
YesNoNot applicable If yes, what was done?
YesNoNot applicable If yes, how many days after the accident?
What was done? How many doctors have you seen?
Please list their names and specialties
Have they helped?
Have you been released from care? ---YesNo
YesNo  If yes, how long after the accident?
YesNo If yes, how many days?
NOTE: Payment for all services is your responsibility. If you intend on using any form of insurance with or without an assignment of benefits, or pay partially for care you receive while being treated here, use health insurance with lower negotiated managed care fees, use an attorney while you await a settlement, or other means of payment, we will assist you in filing for services rendered. Any outstanding balance for all services rendered and not paid, including the difference between the negotiated managed care insurance fees and actual office fees presented to a third party or your attorney, will be your responsibility. Signing below acknowledges this responsibility. If you have a
credit card, we would appreciate keeping an imprint on account in the event a balance remains. Professional collection services may be used to collect outstanding fees and their service charges may be added to your balance.
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