Pulmonary and Medicine Associates

Must be completely filled out in order to process claims

Patients Name *

Address *

Phone Number *

Date of Accident *

Claim Number *

Auto Insurance Carrier *

Claim Submission Address *

Agen's Name *

Agent's Phone Number *

If you are also covered by a medical insurance policy, what insurance is PRIMARY for services related to your automobile accident? *

Medical

Auto

I authorize the release of any medical information necessary to process this claim.
I permit a copy of this authorization to be used in place of the original.
I hereby authorize Pulmonary and Medicine Associates, PLLC to submit claims on my behalf for services rendered.
I authorize that those payments from my insurance company be made directly to Pulmonary and Medicine Associates, PLLC.
I certify that the information I have provided is correct.

Date *

Signature *

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