Notification of Claim or Potential Claim Form

Insured Information

Name Insured

Insured/Policy Number, if known:

Contact Person

Phone Number

Email Address

Other Insurance, if applicable

Potential Claim

Formal Claim/Claim Letter

Notice of Intent

Summons & Complaint

Medical Payments

Refund

Board of Registration Complaint

Dental Records Request

Other

If you received paperwork, please upload same along with this completed document and the patient's complete chart file via the link in the email.

If this notice is based on a conversation, please state the date(s) of the conversation, the parties present, and what was said by each party.

Enter Details Below

Name of patient/claimant:

Address:

Patient Telephone:

Contact person for claimant:

Occurrence Information

Date of incident (if unknown, give treatment dates):

Description of incident or treatment: Alleged Injuries (if known): Other significant information:

Report completed by:

Email Address

Phone Number