"Quick Start Collection Sheet"
Collection of your unpaid Personal Injury Protection (PIP) claims
Litigation against auto insurers
'First Day' Medical Billing Services
Negotiation of payment with patient attorneys
"Bill Assist" program
Quick Start Collection Sheet
Practice/Contact Information
(Please fill in all fields marked with a *)
Practice Name
*
Contact Name
*
Contact Email
*
Patient/Claim Information
(Please fill in all fields marked with a *)
Patient First Name
*
Patient Last Name
*
Address
*
Address 2
City
*
State
*
Zip Code
*
Insurance Company
*
Claim Number
*
Date of Loss
Reason for Denial
IME
Record Review
Other (specify below)
If other
please specify
Amount Paid to date
Amount Due
Does the patient have health insurance?
Yes
No
Patient Attorney
Attorney Phone
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© Ambrose & Ambrose Accelerated Claim Recovery, Inc.
Norwood Corporate Center, 1500 Providence Highway, Suite 22a, Norwood, Mass 02062
P/toll free 877-741-9169 |
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