P.I.-Information

PERSONAL INJURY INTAKE INFORMATION

(Please try to collect as much of the following as possible and bring with you to our office)

1. ACCIDENT REPORT ( liability noted)
2. COPIES OF DRIVERS LICENSE AND SOCIAL SERCURITY NUMBER
3. PHYSICAL AND MAILING ADDRESSES OF THE PATIENT
4. PICTURES OF VEHICLES (If you can get them one or both if possible)
5. PICTURES OF INJURIES
6. COPY OF AUTO/GROUP INSURANCE POLICY OR POLICIES
   1. Med-Pay – patient vehicle
   2. Liability – “At fault party” vehicle (see accident report)
   3. Un-Insured Motorist – patient vehicle
   4. Personal Health Insurance (PHI) – patient general health
7. COPIES OF AMBULANCE TRIP REPORT AND EMERGENCY ROOM NOTES IF ANY
8. COPIES OF URGENT CARE OR MEDICAL DOCTOR VISIT NOTES WITH DIAGNOSIS
9. COPIES OF DIAGNOSTIC TEST RESULTS (XRAYs, MRIs,Ect.)
10. COPY OF AUTOMOBILE INSURANCE POLICY ON EACH AND EVERY VEHICLE IN THE HOUSEHOLD ON THE DAY OF THE COLLISION