This form should only be used when filing claims to 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This is essential for record-keeping.
3. Fill in the Patient Information section, including full name, mailing address, and contact details. Ensure all fields are completed clearly.
4. Indicate the patient's sex and marital status by selecting the appropriate options provided.
5. Complete the Insurance Information section thoroughly, including primary and secondary insurance details. This ensures proper billing.
6. Injury Information should be filled out if applicable, detailing how and when the injury occurred.
7. Finally, review all sections for accuracy before signing at the bottom of the form to confirm that all information is correct.

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