Name		Account Number
Address		Date of Service
City		SSN
State		Home Telephone
Zip Code		Work Telephone
Primary Insurance		Secondary Insurance
Medicare MediCal/Medicaid	Do not fill in information in yellow block for Medicare or Medical/Medicaid.	Medicare MediCal/Medicaid	Do not fill in information in yellow block for Medicare or Medical/Medicaid.
Other		Other
Policy #		Policy #
Group #		Group #
Address		Address
City		City
State		State
Zip Code		Zip Code
Phone #		Phone #
Primary Physician		Physician Telephone
Is the patients condition work related (current or previous)?			Yes No
Is the patients condition related to an auto accident?			Yes No
Please list any additional information that you believe will help get this claim paid.
By submitting this form you are authorizing the release of any medical information necessary to process the above account and any future trips. Additionally, you are requesting payment of government benefits for this and future trips.