MEDICAL CLAIM QUESTIONNAIRE	
Please complete all questions & sign at the bottom	
	
Date of Accident	______________________________	Time of Accident	 ____________	AM	PM	
	
Name  ___________________________________________________	Home Phone # 	________________	
Address __________________________________________________	Work Phone # 	________________	
City, State, & Zip	________________________________________________________________________	
				
Location of Accident	_____________________________________________________________________	
				
To whom did you report this accident?  Please give name & telephone number	________________________	
________________________________________________________________________________________	
	
Please give a description of the accident:	______________________________________________________	
________________________________________________________________________________________	
________________________________________________________________________________________	
________________________________________________________________________________________	
________________________________________________________________________________________	
________________________________________________________________________________________	
________________________________________________________________________________________	
	
What is the nature of your injury?	________________________________________________________________	
________________________________________________________________________________________	
	
Were you treated at the scene of the accident?		YES		NO	
If yes, by whom?	_________________________________________________________________________	
	
Did you seek further medical attention?  		YES		NO	
If yes, please complete the following if applicable:	
Physician or Hospital name? 	_______________________________________________________________	
Address	______________________________________________________________________________	
				
PLEASE SIGN BOTH THIS FORM AND THE MEDICAL AUTHORIZATION FORM ON THE REVERSE SIDE.  RETURN TO THE ADDRESS NOTED ABOVE.  ATTACH ANY MEDICAL BILLS PERTAINING TO THIS ACCIDENT.  THANK YOU.	
	
I have read and completed this statement and it is correct to the best of my knowledge.	
				
	_____________________________________		______________________		
	Signature		Date		

Patient Name:____________________________ Date of Birth:______________

Address:_____________________________________ Apt#__________

City:______________________ State:________ Zip Code:________ Ph#:(___)___________

I hereby authorize__________________________ to release copies of my medical records in their possession concerning my illness, treatment, or recommendations while I was a patient at their medical facility during the dates of:___________________________________________.

These records should be released to:

Name: ______________________________             Phone # (_____) ___________________

Address: ____________________________             Fax # (_____) ______________________
              
               _____________________________

I request the following information be released:
___ Inpatient hospital record  ___ ER/First Care Visit  ___History & Physical  ___ Discharge Summary
___ X-Rays or EKG               ___ Lab/Path report        ___ Day Surgery/Endo. ___ Operative Report
___ Clinical Offices (specify)_______________________     ___ Other (specify)___________________________

I authorize the provider to use or disclose information related to (please initial):
_____ AIDS/HIV and other Communicable Disease
_____ Alcohol and/or Drug Abuse Treatment
_____ Mental Health Services provided by: A clinical nurse specialist; Psychologist; Social Worker; counseling professional; or a physician specializing in psychiatry licensed under the provision of Title 32.

The Purpose for releasing this information is: Legal Purposes

I understand I may revoke all or part of this authorization.  This authorization will be retained as part of my medical record.  I may refuse to disclose all or some of the information in my medical record.  A refusal or revocation to release some or all information may result in improper diagnosis or treatment, denial of insurance coverage or claims for health benefits, or other adverse consequences.  I may cross out any words on this authorization with which I disagree.  I may have a copy of this authorization upon request. This authorization will expire 90 days from the date I sign this form, or upon my request.

____________________________________        _______________________           ___________
Signature of Patient or Legal Representative         Relationship to Patient                     Date

o:\wpfs\claims\claim forms\Medical Claim Questionnaire.doc                                                Revised 11/17/08