Forms (New) - DarLiens, Inc.

Online Health Care Form (New)

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YOUR CONTACT INFORMATION

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Your Name

Your Email

Your Phone

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Doctor's Name

Name of Clinic

Address

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City

State

Zip Code

PATIENT INFORMATION

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Patient Name

Address

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City

State

Zip Code

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Date of Loss

Place Where Accident Occurred

City

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County Where Accident Occurred

Time of Day

Date of Patient's First Treatment

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Is Patient Continuing Treatment?

Is Patient Treatment Complete (Released)?

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Date You Last Saw Patient's For Treatment

Amount Claimed For All Treatments To Date

MEDICAL PAYMENT INFORMATION

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Third Party Insurance Company

Insurance Adjuster Name

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Address

City / State

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Zip Code

Phone

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Claim Number

Policy Number

THIRD PARTY INFORMATION

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Third Party Insurance Company Name

Third Party Insurance Adjuster Name

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Address

City / State

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Zip Code

Phone

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Claim Number

Policy Number

ATTORNEY INFORMATION

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Attorney Name

Name Of Firm

Phone

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Address

City / State

Zip Code

ADDITIONAL COMMENTS

Comment

We have read this complete Authorization and Contract and agree to all the stipulations contained therein, and agree to pay all legal fees should there be any breach of contract, or if I/we supply any forms and or data for use by anyone else not under contract with Dar-Liens, Inc.