HIPAA Form 3010F© 2003 Nationwide Publishing Company, Inc.http://www.claimspages.comMEDICAL AUTHORIZATIONTO WHOM IT MAY CONCERN:I, hereby authorize the release of all medical documentation and other information which may be in thepossession of any insurer, physician, surgeon, hospital, ambulance service or nurse, to any representative of(hereinafter called “The Company”) regarding my injuries, medical history, and physical & mentalcondition both prior to and subsequent to the date of this authorization, regardless of lapsed time.Upon presentation... Download File
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Used as a general release form which is signed by insureds and specifies the payments that are authorized to be issued.
Create your own time line using this Microsoft Excel template. Just enter dates and labels.
Form 3250F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com . Dr. Please furnish the following report regarding my condition. Signed MEDICAL REPORT Name Age Address Occupation Employed by Date of Accident , 20 History as described by patient Date of your first treatment ,20 Date taken , 20 Where taken Findings In...
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Form 2030F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com SUBROGATION RECEIPT RECEIVED FROM (Hereinafter referred to as “Company”) THE SUM OF DOLLARS ($) as a loan, without interest, repayable only in the event and to the extent of any net recovery the undersigned may make from any person, persons, corporations,...
Generic form used by independent adjusters to acknowledge receipt of a property insurance claim, and provide a preliminary report to the insurance company.
Short form for reporting the current status of a claim. Typically used by an independent insurance adjusters.
Form 2070F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com NON-WAIVER AGREEMENT IT IS HEREBY UNDERSTOOD AND AGREED by and between the parties signing this agreement, that any action taken by (hereinafter referred to as “Company”) in investigating the cause of loss, or investigating and ascertaining the amount...
Form 2120F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com PROOF OF HEIRSHIP County of: State of: File Number: We the undersigned, being first duly sworn, do depose and say: First that we are the sole and only heirs of the Estate of deceased, and the relationship which each of us bears to said deceased, is as follows: NAME...
Form 3060F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com AUTHORIZATION To Whom It May Concern: Kindly furnish the bearer of this authorization form any or all information requested. Photocopies of this authorization shall be valid as original documents. WITNESS(ES): SIGNATURE(S): Witness Signature Witness...
Form 2310F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com NON-WAIVER AGREEMENT It is hereby mutually agreed by and between the insured and insurer , as follows; Insurer insures the insured under a Policy Number , with effective dates of through ; and a question exists between the parties hereto as to whether...
Form 3040F © 2003 Nationwide Publishing Company, Inc. http://www.claimspages.com WAGE AUTHORIZATION TO WHOM IT MAY CONCERN: I hereby authorize and any other firm or employer with whom I am or have been employed to release all employment records and information in their possession regarding my wages, hours worked, time lost from work...
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Form 3130F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com RESERVATION OF RIGHTS AGREEMENT It is hereby agreed between hereinafter called Insured, and hereinafter called the Company, which has heretofore issued to the Insured its policy No. that any action taken by the Company in investigating that certain accident...
Form 3140F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com HOLD HARMLESS AGREEMENT I/WE, the undersigned, in consideration of the payment of DOLLARS ($) to be paid by the , hereinafter called the Company, do hereby agree to hold the Company harmless from any further claim in respect to Policy No. or Certificate...
A form which is filled out by the attending physician in order to qualify for medical benefits under an automobile insurance policy.
Form 3230F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com RECEIPT FOR ADVANCE PAYMENT (THIS IS NOT A RELEASE) This is to acknowledge receipt of dollars ($) paid on behalf of to be credited to the total amount of any final settlement or judgment in my/our favor for alleged damages resulting from an accident on...
Form 3240F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com . EMPLOYMENT & WAGE AUTHORIZATION TO WHOM IT MAY CONCERN: YOU ARE HEREBY AUTHORIZED TO GIVE TO , OR ANY OF ITS REPRESENTATIVES, ANY AND ALL INFORMATION REGARDING YOUR EMPLOYMENT, PAST OR PRESENT, INCLUDING RATE OF PAY, DUTIES PERFORMED, DATES OF ABSENCES...
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