Workers Comp

WORKER’S COMP ACCIDENT INSURANCE QUESTIONARE

Must be completely filled out in order to process claims


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.