Once you submit this form we will receive it and contact your carrier directly, please allow us 24-48 business hours to complete this request. Once your claim is verified, you may schedule your first appointment within our office. 

Patient's Name *

First

Last

Patient's Date of Birth *

01/01/2023

Patient's Phone Number *

to Claim Email

Patient's Email *

Patient's Auto Insurance Company *

Select which type of coverage you have on YOUR policy: *

• Medical Payments (Medpay)
• Personal Injury Protection (PIP)
• Other

Patient's Medpay/PIP Claim Number *

What is the date of the injury/accident? *

What is your Medpay/PIP policy limit? (ex: $2k, $5k, $10k, etc.) *

We need this information to try to limit any out of pocket expense for the patient. We try our best to make sure that your expenses are covered by your medpay policy.

Have you had any other care that has utilized your Medpay/PIP policy? *

• Yes
• No
• Unsure

If yes, please describe what treatment and the estimated cost. *

Patients must keep track of their bills being submitted to Medpay/PIP and their remaining available funds.

Medical Claims Adjuster's Name *

First

Last

Medical Claim Adjuster's Phone Number *

Medical Claim Adjuster's Fax Number

Medical Claim Adjuster's Email

Upload a copy of your Auto Insurance Card (or other policy verification document)

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Please upload a copy of your auto insurance card (front and back) or other policy verification document. *You may use your phone to take a photo and upload that photo below, if preferred.

Upload your Massage Referral (if applicable)

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Your healthcare provider may have already faxed us a copy of your referral for massage/manual therapy. However, if you have a copy of it, please upload it here. This helps us quickly and accurately verify your claim.

Capture a photo of your insurance card here Capture With Your Camera

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3

Use Photo Apply Crop

Capture a photo of your insurance card, policy verification document, massage therapy referral or other documents here.

Is there anything else you'd like us to know?

Signature *

Please type your full name as your electronic signature, confirming your identity and the accuracy of the information provided.

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