Medical Insurance Information

1. General Account Information

Please include Diversified's eight-digit account number located on your statement.

Account Number*

Creditor

First Name*

Last Name*

Address*

City*

State*

Zip*

2. Insurance Information

Patient's Date of Birth*

Do you have health insurance?*

Yes
No

Guarantor/Policy Holder's Name

Insurance Company Name*

Policy Number

Group Number

Employer Name

Employer Address

3. Legal Information

Was this a Work Related or Personal Injury?

Yes
No

Are you represented by an attorney?

Yes
No

Attorney Name

Attorney Number

Do you have Medical Assistance/Medicaid?

Yes
No

Medical Assistance/Medicaid Number

Do you have Medicare?*

Yes
No

Medicare Number

4. Telephone Disclaimer

Your Phone Number*

Telephone Disclaimer*

By checking this box, you are confirming that you are the named individual on this account and are authorized to review and discuss any personal information contained in the account. You further authorize Diversified Adjustment Service, Inc., representatives to contact you at by telephone at any and all numbers you have provided to discuss the account, including but not limited to contact via prerecorded messages and calls made by an automated telephone dialing system. You agree and confirm that the telephone number you provide belongs to you.

I Acknowledge and Agree

5. Email Disclaimer

Your Email Address*

Email Disclaimer*

You agree that Diversified Adjustment Service, Inc. may from time to time make calls and/or send text messages to you at any telephone number associated with your account, including wireless telephone numbers that could result in charges to you. You hereby confirm that any number you provide belongs to you. The manner in which these calls or text messages are made to you may include, but is not limited to, the use of prerecorded/artificial voice messages and/or automatic telephone dialing system. You further agree that Diversified Adjustment Service, Inc. may send e-mails to you at any e-mail address you provide us or use other electronic means of communication to the extent permitted by law. You agree and acknowledge that any e-mail address or any other electronic address that you provide is your private address and is not accessible to unauthorized third parties. You agree and acknowledge that you have requested that we send the document(s) you have requested to you at the e-mail address you have provided. Consent may be revoked at any time and by any reasonable means.

I Acknowledge and Agree

6. Comments / Document Attachments

Your Message

Upload Documents

Please attach a copy of your health insurance card (both sides) below

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