Insured's Information

Section 1 - Accident Information

Section 2 – Other Insurance Information

If yes, please provide the information below.

Section 3 – Authorizations

If under the age of 18, please provide Parent / Guardian’s information below.

Authorization and Release Information

I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information, to Administrative Concepts, or their employees and authorized agents for the purpose of validating and determining benefits payable. A photocopy of this authorization shall be as valid as the original. I certify the above information to be true and correct.

Authorization to Pay Provider

I authorize payment of charges associated with this incident directly to the physicians or providers. I further certify that the foregoing information is true and correct.

Section 4 - Organization / Program

To be completed by the Organization / Program