Interview Slip and Fall

INVESTIGATION INFORMATION

Client Name
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Date of Birth
Social Security Number
Emergency Contact
First Last
Emergency Contact Phone Number
Marital Status
Spouses Name (If Applicable)
First Last
Health Insurance
Does Client Have Health Insurance
Does Client Have Government Insurance? (Medicare)
Health Insurance Carrier
Carrier Phone Number
Subscriber's Name
First Last
Member Number
Medical Providers
Was Client Treated By Paramedics?
Was Client transported to Hospital via Ambulance?
Name of First Hospital/ Doctor Seen:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Were X-Rays Taken?
Name of others doctors seen
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Has Client Received Any Medical Bills?