Auto-Accident form

Automobile Accident Insurance Questionare

Must be completely filled out in order to process claims

Patient's Name

Address

Phone Number

Date of accident

Claim Number

Auto Insurance Carrier

Claim Submission Address

Agent's Name

Agent's Phone Number

If you are also covered by a medical insurance policy, what insurance is primary for services related to your automobile accident?

Medical Auto

I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original.

I hereby authorize Macomb Physicians Group, PLLC. to submit claims on my behalf for services rendered.

I authorize that payments from my insurance company be made directly to Macomb Physicians Group, PLLC.

I certify that the information | have provided is correct.

Signature

Date

Auto-Accident form

Automobile Accident Insurance Questionare

Must be completely filled out in order to process claims

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