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    Section 1.   Identification


    Section 2.    Accident Description

    Please complete and attach all itemized copies of any bills including physicians, hospitals, emergency rooms, ambulance, and rehabilitation center.
    If Auto accident or Assault, please attach a copy of the police report.
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB

    Section 3.   Doctor's Information

    Date the doctor first treated this condition
    If yes, When were you admitted?

    Treating Physician


    Primary Care Physician


    Hospital 


    Section 4 - Treatment Information

    Max file size: 20MB
    Please download, complete, and upload your HIPAA release form here

    By signing and dating this application, you are confirming that all the above information is legitimate and correct
    Please type your name to verify
    MM/DD/YYYY
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Copyright © 2022
  • Forms
  • Our Products
    • Hospital Income
    • Heart
    • Cancer
    • Accident
    • Intensive Care
  • Agent Services
    • Employee Email Log-In
    • Career Opportunities
    • Agent Training Material
  • Portal Access Link
  • Wealth Care Admin