West Palm Beach Florida car accident information regarding Health care costs Call 1-800-74-TRIAL

Health Care Provider: ________________________________________________

Address: _____________________________________________________________

Telephone: ____________________________

Fax: __________________________________

Appointment Secretary or Other Contact Person: _______________________

Recordkeeper: ________________________________________________________

Billing Clerk: _______________________________________________________

Supervising Physician: _______________________________________________

Requests for Medical/Treatment Records:

DATE RECEIVED DATE OF DATE
Yes/No FOLLOW-UP RECEIVED
REQUEST
__________
__________
__________
__________
__________
__________
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__________

Requests for Billing Information:

DATE RECEIVED DATE OF DATE
Yes/No FOLLOW-UP RECEIVED
REQUEST
__________
__________
__________
__________
__________
__________
__________
__________

Requests for Medical Expenses:

DATE RECEIVED DATE OF DATE
Yes/No FOLLOW-UP RECEIVED
REQUEST
__________
__________
__________
__________
__________
__________
__________
__________

Requests for Psychological/Psychiatric Records:

DATE RECEIVED DATE OF DATE
Yes/No FOLLOW-UP RECEIVED
REQUEST
__________
__________
__________
__________
__________
__________
__________
__________

Requests for Billing Information (Psychological/Psychiatric Records):

DATE RECEIVED DATE OF DATE
Yes/No FOLLOW-UP RECEIVED
REQUEST
__________
__________
__________
__________
__________
__________
__________
__________

Requests for Psychological/Psychiatric Expenses:

DATE SERVICE AMOUNT PAYMENT
INCURRED PERFORMED HISTORY
Yes/No
__________
__________
__________
__________
__________
__________
__________
__________