Motor Vehicle Accident Information
Date of Accident?
Describe the Accident:
Were you taken to the Emergency Room?
Were X-Rays taken? Results:
Name of auto insurance carrier:
Telephone #: Adjustor:
Name of insured: Claim#:
Are you the policy holder? If not, who is? Relation to you?
Name of attorney: Telephone #:
We will bill your insurance company directly. You are responsible for any charges not covered
by your insurance.
YOU ARE RESPONSIBLE FOR YOUR BILL IF INSURANCE DOES NOT PAY.
(initial) PIP (Personal Injury Protection) Coverage IS NOT a guarantee that your physical
therapy will be paid.
I understand and agree to the above-mentioned terms. I hereby consent for physical therapy
Patient Signature Date