*    Indicates required fields
NOTE: Please complete the following required fields.* Upon submission you will receive an acknowledgement email. Please do not place this completed form or that email in the patient’s medical chart. Keep all information related to this matter in a separate legal file.
Date of Report:
REPORTER INFORMATION
Please provide the required information for the individual reporting the matter ("Reporter")
*    Reporter Full Name:
*    Reporter Email:
*    Confirm Reporter Email:  
*    Reporter Phone:  
*    Has this matter been previously reported to us?:
REASON FOR REPORT   *  









INSURED INFORMATION
*    Insured Full Name:
Insured Policy #:
*    Insured Practice State:  
*    Insured Preferred Email (to be used for all written communication):
*    Confirm Preferred Email:
Phone # (if different from above):  
PATIENT/CLAIMANT INFORMATION
*    Full Name:  
Date of Birth:
Date of Treatment triggering this report:

Directions: Please attach any claim related correspondence, legal documents and medical records related to this patient prior to submitting form. You will receive email confirmation upon our receipt of your submission.

Attachment:
Attachment:

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