IC 24-5-13 5 Chapter 13 5 Buyback Vehicle - State of Indiana - seattleu 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, including last name, first name, and middle initial. Ensure accuracy for proper processing.
3. Fill in the address fields: street, city, state, and zip code. This information is crucial for communication regarding your claim.
4. Provide the phone number and social security number or student ID number. This helps verify your identity and eligibility.
5. Indicate the date of birth and gender of the patient. This information is often required for insurance processing.
6. Detail the nature of the injury or illness and provide specifics about how, when, and where the accident occurred if applicable.
7. Complete sections related to parental/guardian information if necessary, including their contact details and employer's name.
8. Review all entries for accuracy before signing the authorization sections at the end of the form to release information and authorize payment.

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