| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |
|---|---|---|---|---|
| OK-41-013-22-200-E | 10/23/2022 | CMS-for-Incident-.pdf | ||
| TX-AK-305-23-9-E | 09/28/2023 | CMS-for-Incident-.pdf | ||
| AL-01-403-23-1213 | 11/07/2023 | NATIONAL GENERAL INSURANCE | PASCAUL RUIZPREZ | CMS-for-Incident-2013159821.pdf |
| TX-SH-201-C23-23917-EE | 09/14/2023 | PROGRESSIVE INSURANCE – MEDICAL | CMS-for-Incident-19284835.pdf | |
| TX-SH-201-C23-23917-E | 09/14/2023 | PROGRESSIVE INSURANCE – MEDICAL | RAFORD STERLING | CMS-for-Incident-19284835.pdf |
| TX-BB-326-23-208-EE | 10/28/2023 | PROGRESSIVE INSURANCE – MEDICAL | CMS-for-Incident-955187694.pdf | |
| TX-BB-326-23-208-E | 10/28/2023 | PROGRESSIVE INSURANCE – MEDICAL | CMS-for-Incident-955187694.pdf | |
| TX-XV-414-23-1802-E | 11/04/2023 | USAA INSURANCE – MEDICAL CLAIMS | CMS-for-Incident-0161860297104.pdf | |
| TX-AC-501-23-1026-E | 10/26/2023 | QUINNON GARDNER | CMS-for-Incident-.pdf | |
| TX-AC-501-23-1026-EE | 10/26/2023 | ROLANDO REYES | CMS-for-Incident-.pdf | |
| OK-49-015-23-682-E | 11/03/2023 | LOYA INSURANCE COMPANY | BRANDY LEMMON | CMS-for-Incident-788-6862828.pdf |
| TX-CX-409-23-66-E | 10/22/2023 | REDPOINT COUNTY MUTUAL INSURANCE CO. | CMS-for-Incident-BGS01020258.pdf | |
| AL-01-403-23-743-E | 07/18/2023 | STATE FARM | CMS-for-Incident-0135727460.pdf | |
| KY-50-852-23-103-E | 09/25/2023 | ERIE INSURANCE | TARA SMITH | CMS-for-Incident-Q07-0411732.pdf |
| TX-AC-501-23-104-E | 01/04/2023 | AMERICAN HALLMARK INSURANCE SERVICES | KODY HALL | CMS-for-Incident-642427113.pdf |
| TX-AC-501-23-104-EE | 01/04/2023 | AMERICAN HALLMARK INSURANCE SERVICES | KONNOR TAYLOR | CMS-for-Incident-642427113.pdf |
| TX-SH-201-C23-21056-E | 08/14/2023 | ALLSTATE PIP / MED PAY | CMS-for-Incident-436176130.pdf | |
| TX-AZ-409-23-93-E | 08/27/2023 | OLD AMERICAN COUNTY MUTUAL | JAMES BURGOON | CMS-for-Incident-15TX6041941.pdf |
| TX-CW-201-23-3140-E | 09/05/2023 | GARRISON PROPERTY & CASUALTY | CMS-for-Incident-02301-45-36R-7101-9.pdf | |
| TX-AK-305-23-8458-E | 02/23/2023 | CMS-for-Incident-.pdf | ||
| OK-59-007-23-53-E | 05/12/2023 | JOHN NASH | CMS-for-Incident-.pdf | |
| OK-59-007-23-51-E | 04/21/2023 | FARMER'S INSURANCE | CMS-for-Incident-A7997748060.pdf | |
| OK-59-007-23-51-EE | 04/21/2023 | FARMER'S INSURANCE | SCOTTY KELLEY | CMS-for-Incident-A7997748060.pdf |
| AL-01-403-23-660-E | 07/01/2023 | STATE FARM | REBA HEADLEY | CMS-for-Incident-0134169063.pdf |
| TX-HP-309-23-195-E | 07/02/2023 | STATE FARM MUTUAL INSURANCE | CMS-for-Incident-331-0079-D27-43J.pdf | |
| Incident Number | Date of Loss | Insurance Company Name | Patient Name | CMS Claim Form |