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info@macombphysicians.com
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Physicians
Services
Preventative Medicine
Medical Weight Management
Screenings and Diagnostics
Primary Care
Allergy Testing
Diabetes
Hypertension
Annual Wellness Exams
Patient Forms
Patient Portal
Contact Us
Workers Comp
WORKER’S COMP ACCIDENT INSURANCE QUESTIONARE
Must be completely filled out in order to process claims
Patient's Name
Address
Phone Number
Date of accident
Claim Number
Description of injury
Insurance Carrier
Claim Submission Address
Employer
Phone Number
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 I have provided is correct.
Signature:
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Date
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