Home Page - Report of Claim

* 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:		Email Address do not match
* Reporter Phone:
* Reporter Company:
* Has this matter been previously reported to us?:	YesNo

REASON FOR REPORT *

Record Request
Dissatisfied Patient
Verbal or Written Notice of Claim
Lawsuit
Administrative Defense (St. Board Investigation/Billing Errors Proceeding/Employment-Related Civil Action)
Cyber Security (Information or Network Security Breach/Regulatory Privacy Proceeding/Customer Notification & Credit Monitoring)
General Liability (Bodily Injury & Property Damage)
Notice of Deposition
Unexpected Outcome
Other

INSURED INFORMATION
* Insured Full Name:
Insured Policy #:

* Insured Practice State:
* Insured Preferred Email (to be used for all written communication):
* Confirm Preferred Email:		Email Address do not match
Phone # (if different from above):
PATIENT/CLAIMANT INFORMATION
* Full Name:

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:

Only click the Submit Form button once.

REPORT OF CLAIM OR POTENTIAL CLAIM

PRIVILEGED AND CONFIDENTIAL

Date of Birth:
Date of Treatment triggering this report: