Skip Navigation
Skip Main Content

COMPREHENSIVE HEALTH CENTER

Please complete this field.
Please complete this field.

PATIENT INFORMATION:

PATIENT INFORMATION:

Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

CLAIM INFORMATION:

CLAIM INFORMATION:

TYPE OF CLAIM:
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

PATIENT'S RELATIONSHIP TO INSURED:

PATIENT'S RELATIONSHIP TO INSURED:

IF THIS IS A PERSONAL INJURY CLAIM, WHO IS INSURED?
Please select an option.
IF INSURED IS OTHER THAN PATIENT PLEASE COMPLETE:
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

ATTORNEY INFORMATION:

ATTORNEY INFORMATION:

Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

OTHER INSURANCE:

OTHER INSURANCE:

MEDICAL INSURANCE (OTHER THAN HMO OR PPO)
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

ACCIDENT INFORMATION:

ACCIDENT INFORMATION:

DID YOU GO TO A HOSPITAL?
Please select an option.
Please complete this field.
DID YOU HAVE:
Please select an option.
Please complete this field.
DO YOU HAVE A COPY OF THE POLICE REPORT?
Please select an option.
DID YOU RECEIVE A TRAFFIC TICKET?
Please select an option.
Please complete this field.
Please complete this field.
1. AT THE TIME OF THE ACCIDENT, DID YOU OWN THE VEHICLE?
Please select an option.

IF YES: CONTINUE TO QUESTION 2

IF NO: CONTINUE TO QUESTION 4

2. WAS IT INSURED WITH PIP INSURANCE AT THE DATE OF THE ACCIDENT?
Please select an option.

IF YES: CONTINUE TO QUESTION 3 AND STOP

IF NO: NO COVERAGE! DO NOT CONTINUE

3. AT THE TIME OF THE ACCIDENT WAS ANYONE LIVING WITH YOU WHO HAD A DRIVER'S LICENSE AND DID NOT OWN A CAR?
Please select an option.
4. AT THE TIME OF THE ACCIDENT, WERE YOU LIVING WITH RELATIVES WHO OWNED A VEHICLE?
Please select an option.

IF YES: CONTINUE TO QUESTION 5 AND STOP

IF NO: CONTINUE TO QUESTION 6

5. DOES MORE THAN ONE RELATIVE THAT YOU LIVE WITH - HAVE A VEHICLE INSURED WITH PIP INSURANCE?
Please select an option.
6. DID THE OWNER OF THE VEHICLE THAT YOU WERE INJURED IN HAVE PIP INSURANCE?
Please select an option.

TREATMENT AUTHORIZATION

TREATMENT AUTHORIZATION

Please complete this field.
Please complete this field.
  1. I, the signed, authorize the Comprehensive Health Center to do the necessary medical and laboratory required for the study of diagnoses and treatment of my illness by the corps of doctors of this center.
  2. I am aware that the medical practice is not an exact science, therefore the doctors cannot guarantee the outcome of the treatments and laboratory tests done in this center.
  3. I authorize the release of information to other institutions or agencies that accept me as patient to receive other medical attention and / or hospitalization. I also give authorization to facilitate medical information on my condition to the insurance company.
  4. By those means, I authorize the Comprehensive Health Center, LLC. To receive payment for medical services rendered to me from my insurance company. The amount of such payments will not exceed the fees charged by the center and / or doctors for the treatment of my condition. I agree to accept a photostatic copy of this authorization.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

E-signature image