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AUTOMOBILE ACCIDENT INFORMATION FORM

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									                                             AUTOMOBILE ACCIDENT CLAIM FORM
MRI/MRA
Imaging
Centers
                               LOCATION:
Bio-Magnetic Resonance, Inc.
30781 Stephenson Highway                                                                            MR#:
MadIson HeIgHts, MI 48071                      (Patient’s full name printed)
(248) 585-5115
                               Auto Insurance Carrier:
FAX (248) 585-0234
                               Claim Number:
                               Date of Injury/Accident:
                               Adjusters Name:

the Imaging Center             Adjusters Phone Number:
15670 Southfield Road
allen PaRk, MI 48101           1) Were you the owner of the vehicle involved in the accident? Yes          No
(313) 294-2897
FAX (313) 294-2915             2) Were you the Driver       a Passenger       or a Pedestrian

                               3) Is this your auto insurance policy? Yes        No       If yes go to question 9.

                               If you answered no to Question 3 please answer the following.
Bio-Magnetic Resonance, Inc.
                                       4) Whose insurance are you making a claim with?
25100 Kelly Road
RosevIlle, MI 48066
                                       5) Did you own an insured vehicle at the time of the accident? Yes         No
(586) 445-4900
FAX (586) 445-4902                     6) Do you have your own auto insurance policy?
                                              Auto Insurance Carrier:
                                               Policy Number:
                                       7) Please provide your address at the time of the accident:
                                              Address 1:
Biomagnetic Imaging Center
960 River Centre Drive                         Address 2:
PoRt HuRon, MI 48060                           City:                                 State:        Zip:
(810) 966-8523
FAX (810) 966-5056
                                       8) Were there any relatives residing in your household with insured vehicles at the time
                                          of the accident? Yes       No      If no, go to question 9

                                               8.a) The following relatives in my household own vehicles:
                                               Name:
the Imaging Center
                                               Relationship: Spouse         Parent      Child   Other please specify:
4447 Talmadge, Suite H
toledo, OH 43623                               Auto Insurance Carrier:
(888) 674-8653                                 Name:
FAX (888) 674-8650
                                               Relationship: Spouse         Parent      Child   Other please specify:
                                               Auto Insurance Carrier:
                               9) Were you on the job when the accident occurred? (This does not include you usual commute
                               to and from work) Yes     No
(888) MRI-todaY
       (674-8632)
www.biomagmri.com
                                               AUTOMOBILE ACCIDENT CLAIM FORM
MRI/MRA
Imaging                        10) Was a police report made? Yes            No
Centers
                               11) In which city did this accident occur?
Bio-Magnetic Resonance, Inc.
30781 Stephenson Highway       12) Were you treated at a hospital emergency room, Yes               No
MadIson HeIgHts, MI 48071      If yes where?
(248) 585-5115
                               13) List any injuries that were a direct result of this accident:
FAX (248) 585-0234




the Imaging Center
                               14) Have any payments been issued by the auto insurance carrier for this no-fault claim for any
15670 Southfield Road
                               of the following: (check all that apply)
allen PaRk, MI 48101
                               Wage loss reimbursement          Replacement services Medical Treatment         I don’t know
(313) 294-2897
                               Other      (please specify)
FAX (313) 294-2915

                               15) Are you collecting any other benefits from the following?
                               Social Security Disability               Long-term Disability
                               Workers Compensation                     Short-term Disability
                               Unemployment benefits
Bio-Magnetic Resonance, Inc.
25100 Kelly Road               16) Do you have any other Health Care Insurance? Yes                No
RosevIlle, MI 48066
(586) 445-4900
                               Carrier Name:                                         Phone Number
FAX (586) 445-4902
                               Policy Number:
                               Subscriber Name:
                               Is this insurance through your employer? Yes          No    - Employer Name:

Biomagnetic Imaging Center     Carrier Name:                                         Phone Number
960 River Centre Drive         Policy Number:
PoRt HuRon, MI 48060
                               Subscriber Name:
(810) 966-8523
FAX (810) 966-5056             Is this insurance through your employer? Yes          No    - Employer Name:

                               Medicare         Contract number:

                               Medicaid         ID number:

the Imaging Center             17) Do you have an attorney representing you for your no-fault claim? Yes       No
4447 Talmadge, Suite H
toledo, OH 43623                       Attorney Name:
(888) 674-8653                         Attorney Phone Number:
FAX (888) 674-8650
                                       Attorney Address:
                                       City:                                State:                      Zip:


                               Patient Signature                                                        Date
(888) MRI-todaY
       (674-8632)
www.biomagmri.com                 Revised 1-21-10

								
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