Medical Insurance Form

Direct Documents
Rep's first name: Rep's last name:
Rep's email:

Underwritten by: Policyholder:
Policy number: Claim number:
Date of loss: Today's date:

  Treating note   Dental Records
  ER notes   Current charges to date
  Physician's notes   Discharge Summary
  X-ray interpretations   Attending Physician's Report
  Surgical Notes   Narrative Reports
  Past medical records   CT/MRI Scan Report

*** Please fax or e-mail the signed Medical Authorization Release of Information form and reference claim number to 888-711-1577 or***