NORCAL Group of Companies

Norcal




REPORT OF CLAIM



PRIVILEGED AND CONFIDENTIAL
NOTE:
  • Do not place this completed form in the patient's medical chart. Instead put any copies in a separate legal file.
  • If you are e-mailing this form instead of using our online submission tool, we suggest you encrypt the message to be HIPAA compliant.

 *   Required Field
Date:9/24/2016
Reported by:  *
Reporter's Email:    *

REASON FOR REPORT
 
 
 
 
 
 
Docket #:   
Date of Service (MM/DD/YYYY)
County:   
State:
 
 






 
 

INSURED INFORMATION:
Name:  *
Specialty:
Address:  *
 
City:  *
State:  *
Zip:  *
Business Phone #:  *
 -   - 
Cell Phone #:
 -   - 
Email:
Contact Person:
Contact Phone #:
 -   - 
Group/Policy Holder:
Policy #:
Dates of Coverage/Limits:
Shared Limits:
Yes with   
Other Insurance:
  If Yes, with   


PATIENT INFORMATION:
Name:  *
Address:
 
City:
State:
Zip:
Phone #:
 -   - 
Date of Birth (MM/DD/YYYY):
Age:   
Deceased:
Date of Death (MM/DD/YYYY):   
Gender:  *
Marital Status:
Dependants:
Medicare:
Medicaid:   
Plaintiff Attorney:
    Firm:
    Address:
 
    City:
    State:
Zip:
    Phone #:
 -   - 


CLAIM INFORMATION:
Date of Incident
(MM/DD/YYYY):
 *
Location of Incident:
Other Involved Treaters/Hospitals (List):
Description of Incident/Facts (Brief):  *

Directions:
Please attach any claim-related correspondence, legal documents, and medical records related to this patient.
Attachment :
Attachment :