Letter of Protection Authorization Form

Letter of Protection Authorization Form
Authorize your healthcare provider to receive payment for services related to your accident or injury. Please complete all sections accurately.
Patient Full Name
First NameLast Name
Patient Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Accident/Injury
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Description of Accident/Injury
Treating Provider/Clinic Name
Provider/Clinic Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attorney or Law Firm Name
Attorney/Law Firm Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attorney/Law Firm Email Address
example@example.com
Insurance Company Name (if applicable)
Policy or Claim Number (if applicable)
Patient Signature
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