Test Field Case Management - Medlogix

Field Case Management

Service Information

Service Request

Type of Coverage

Claimant Information

Name

Address

Address Line 1

City

State

Zip Code

Phone

Cell Phone

Contact Person

Social Security

Date of Birth

Address

Address Line 1

City

State

Zip Code

Phone

Cell Phone

Employer Information

Employer Name

Address

Address Line 1

City

State

Zip Code

Phone

Fax

Nature of Business

Contact Person

Contact Phone

Contact Email

Carrier Information

Carrier Information

Carrier

Address

Address Line 1

City

State

Zip Code

Adjuster

Phone

Fax

Insured Amount

Policy Limit

Deductible Amount

Accident Information

Accident Date and Time

Claim Number

Diagnosis

Physician(s)

Hospital(s)

Contact Phone or Beeper Number

Patient Attorney Information

Is the patient represented?

Yes

No

Attorney Name

Firm Name

Address

Address Line 1

City

State

Zip Code

Fax

Phone

Comments

Comments, Instructions, and Other Pertinent Data