Abogado / Firm

Abogado Name *

Law Firm *

Phone *

Email *

Fax

File / Matter No.

Paciente Information

Paciente Nombre *

Paciente Apellido *

Fecha de Nacimiento *

Paciente Phone

Date of Injury *

Injury Type *

Insurance & Billing

Billing Type *

Insurance Carrier

Número de Reclamo

Policy Number

Servicios Requested

Notes

Clinical notes, urgency, scheduling preferences

Aviso HIPAA: All information is transmitted securely and handled per HIPAA privacy standards.

By submitting you confirm authorization to refer this paciente and consent to MAIC contacting your office to confirm intake.

Referencia Enviarted

Our PI coordination team will contact your office within 2 business hours to confirm intake and schedule the paciente.

Urgent? Call now: (888) 991-5290

Your Information

Nombre *

Apellido *

Número de Teléfono *

Fecha de Nacimiento

Preferred Language

Nosotros Your Injury

Date of Injury *

How Were You Injured? *

Insurance & Abogado

Do You Have an Abogado?

Coverage Type

Abogado Name (if applicable)

Preferred Cita Time

Anything Else?

Additional information or questions

We will never charge you out-of-pocket for your visit. If you were injured in an accident, your tratamiento is covered. We'll explain your coverage when we call.

By submitting you consent to MAIC contacting you by phone to schedule your cita. Your information is kept confidential per HIPAA.

Request Received

A member of our team will call you within 2 hours to confirm your cita.

Need sooner? Call: (888) 991-5290

Referir un Paciente to MAIC

Referencia & Cita Request

Médicos Treating Your Referencias

¿Listo para Referir a Su
Next PI Case?

Referir un Paciente to MAIC

Referencia & Cita Request

Médicos Treating Your Referencias

¿Listo para Referir a SuNext PI Case?

¿Listo para Referir a Su
Next PI Case?