| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |
|---|---|---|---|---|
| TX-KP-401-23-30-E | 02/03/2022 | HOME STATE COUNTY MUTUAL INSURANCE | SETH WHITMER | CMS-for-Incident-00102807.pdf |
| TX-SH-201-C23-02139-E | 01/24/2023 | GEICO INSURANCE – MEDICAL | CMS-for-Incident-0952138808.pdf | |
| TX-SH-201-C23-02139-EE | 01/24/2023 | GEICO INSURANCE – MEDICAL | JAZMIN LEDAY | CMS-for-Incident-0952138808.pdf |
| AL-01-403-23-91-E | 01/23/2023 | ALFA INSURANCE | STEPHEN KILEY | CMS-for-Incident-A2260471.pdf |
| AL-01-403-23-16-E | 01/05/2023 | ACE AMERICAN INSURANCE | LOYCE FULGHAM | CMS-for-Incident-ISAH2555932A.pdf |
| TX-CW-201-22-462446-E | 07/12/2022 | PROGRESSIVE COUNTY MUTUAL INSURANCE | CMS-for-Incident-950668177.pdf | |
| TX-CW-201-22-464039-EE | 07/30/2022 | STATE FARM COUNTY MUTUAL INS. TEXAS | SAMUEL RAMOS | CMS-for-Incident-485-8552-G15-43-001.pdf |
| TX-CW-201-22-464039-E | 07/30/2022 | STATE FARM COUNTY MUTUAL INS. TEXAS | CMS-for-Incident-485-8552-G15-43-001.pdf | |
| TX-CW-201-22-461825-E | 07/05/2022 | TEXAS FARM BUREAU | CMS-for-Incident-23242711.pdf | |
| TX-CW-201-23-476629-E | 01/12/2023 | STATE FARM MUTUAL INSURANCE | BRANDON MORRISON | CMS-for-Incident-365-6176-K05-43A-001.pdf |
| AL-50-022-22-1529-A-E | 12/11/2022 | ARCH INSURANCE GROUP CLAIMS DEPARTMENT | CMS-for-Incident-ZACAT7002902.pdf | |
| TX-CW-201-22-474598-EEEE | 12/16/2022 | GERMANIA INSURANCE COMPANY | GRACIE CLARK | CMS-for-Incident-2302211027945.pdf |
| TX-CW-201-22-474598-EEE | 12/16/2022 | GERMANIA INSURANCE COMPANY | JORDAN CARRIKER | CMS-for-Incident-2302211027945.pdf |
| TX-CW-201-22-474598-EE | 12/16/2022 | GERMANIA INSURANCE COMPANY | NATHAN WOOTEN | CMS-for-Incident-2302211027945.pdf |
| TX-CW-201-22-474598-E | 12/16/2022 | GERMANIA INSURANCE COMPANY | CMS-for-Incident-2302211027945.pdf | |
| TX-BY-205-22-0920-CMS | 09/20/2022 | PROGRESSIVE INSURANCE – MEDICAL | CMS-for-Incident-22-7529266.pdf | |
| TX-WZ-208-22-129-E | 10/30/2022 | GEICO INSURANCE – MEDICAL | LUIS JUAREZ | CMS-for-Incident-44-999-19-670.pdf |
| TX-HW-405-22-164-E | 12/30/2022 | STATE FARM MUTUAL INSURANCE | CMS-for-Incident-510-490-J13-43A-002.pdf | |
| OK-49-015-22-8231-E | 12/23/2022 | HERTZ | CMS-for-Incident-.pdf | |
| AL-01-712-22-159-E | 12/09/2022 | LIBERTY MUTUAL - MEDPAY | KERRY MORGAN | CMS-for-Incident-AS2631510797012.pdf |
| AL-01-717-22-1209-E | 12/09/2022 | LIBERTY MUTUAL - MEDPAY | KERRY MORGAN | CMS-for-Incident-AS2631510797012.pdf |
| TX-SH-214-22-31527-E | 12/05/2022 | HOME STATE COUNTY MUTUAL INSURANCE | PAMELA SMITH | CMS-for-Incident-29297.pdf |
| TX-SH-201-C22-31527-E | 12/05/2022 | HOME STATE COUNTY MUTUAL INSURANCE | PAMELA SMITH | CMS-for-Incident-29297.pdf |
| TX-RN-424-22-1597-E | 05/07/2022 | USAA INSURANCE – MEDICAL CLAIMS | ANTHONY BUMPERS | CMS-for-Incident-TX-RN-424-22-1597-E.pdf |
| AL-02-006-22-346-E | 12/05/2022 | ACORD INSURANCE-MEDICAL | CARL WEEKS | CMS-for-Incident-GL2207476-90034.pdf |
| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |