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Sure Fire Recovery Service

You Help Them.... We Help You

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Insurance Company Information

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Incident Details

Date of Loss(Required)
This field is to be filled in with the Insured ID Number (Policy #, Claim #, etc.)

Insured Information

Insured Name
Insured Address
Insured Date of Birth

Patient Relationship Status

Relationship to Insured
Address Same as Insured?

Patient Information

Patient Name
Patient Address
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Patient Address - Same as Insured
Patient Date of Birth
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PDF Patient Information

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PDF Patient Name
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PDF Patient Address
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PDF Patient Date of Birth
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Medical Details

CPT Code Choices Qty Used Product Charge Date Of Loss CPT Code CPT Description CPT Price Place of Service Code EMG Code Diagnosis Pointer Actions
                   
There are no Codes.

Maximum number of codes reached.

V49.9XXA code extrication only
V89.2XXA CMS code only
Price: $0.00
Incident Location

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