MEEMIC application for benefits

Comments

Transcription

MEEMIC application for benefits
May031109:57a
United Wellness Flint
8102 337255
,1';t~~;:.
MEEMIC INSURANCE C""'~PANY
:1:\\:;;·
:t
'::'\. '.r:-. I"
10tl:J NORTH OPDYKE ROAI:.
p,5
MICf-IlGAN MOTOR VEHICLE
NO-FAULT INSURANCE LAW
t"lt~Pu:,·;~.j~~I' AURURN HILLS, MICHIGAN 48326-2656
-'-' Of~t:~btN«~
.•••,., ........
.
1-8M-iI-MECMIC
Application For Benefits
IlJIII
OWl I 'Ol l!;Y u():,uuf
,,\[1.
:IAIMNLJMUI){
"
TO:
rHE NO-FAUL'r lAW PROVIOL~ BEN[FITS r OH MI::DICI\L l..xI ' ENSCS. V'IAG£ LO:)(; 1\1010 HEPI.JIC[t.lf.N I' S I::KVICr,~; , AS WElI _A~. :">lJHVIVORzj' 1 a~, TO
[NAOLt U!} TO D[TEI~MINl ', If' YOU "HI ' rNnTU'O TQANY OF TIIU~L B[N[rJT~ . GOMI>LCTC 1 Iii!; Af"PUCI\TlQN FORM AND naURN PROMPn y ,
'API-'IIC;ANT'S NIIMI (11I'~.1 N:lmo. M'OcOO Ini~;]I. L,,,.l N.l~)
h-,....,
["
--- - . : - ._-
aU~INl::;~' I-'HONL
.1
I\[JUkES::; (N(),. Stroof,'"dty ,,( lawn. Stille. ~ Ip)
'-----~---....L..~--"I""
jl-;-:H"'I~:::;Dc:I\c:I-;-I---.....,...-:-=-::+-;;-;-:::;-;CC-;:-~
rlACE Ol ' l\CCIDENr
IU(, r(AND TIME OF ACCTDE:.N I
',(Xl.
your GpolJ:j.l ~ .
Of
(Stroot. City or Tow". $t;JIE')
YOV fJr
your 3DOtJ.:;t~ ((!,l'otdm9
[=:::J CIII-r.K I-P°H I.
n' °1HE:ru: I\r:ll.: N lJ
VI.l°HCl.I ~. IN HOU$U 101 n
IT,~f(,~.~~~;:'~
I I
r\~~~PO'WC~NCt1:;J~:-'~
.-----...
... -----------... -----....-- ... ------- -------- _-_ ...--_ .. _-_....--------_ ...
.. _-------___ _________________ - _______ ____
______________ __________ • ___ --____ ....... __ - _______________ --__ . . . __________________
....... ------~
----........--~-----
.~
~~
~
~_"
.....
•______ ___ w_-_____ • ___________- ____ _ . . . _________ ·" _____ _______
~
~
~
--_
~
u_~
---.~~--------------------------------.-.---------~-------
.__________ --w-____ __ _________________ _____________________ -________
~ --
.....
~
~
r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ... _ _ _ _ _ _ _ _ _ - -
______ •
__
May031109:57a
United Wellness Flint
8102337255
p.6
tion For ..... ~nefits
If YCS. Qivo name....ddress and ohQn(! of doctor[s) p!'QVidin(l trwtment:
- ~-~-------- _ _ _ _ _ _ _ _ __ ______ ~ ____ w __ -_~ ________ w _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • • __ w ___ ~~ ____ ~
--- -
...... ---------------
-~
... "... - - - - - _ ...
_- - - - - - - - -_ .............. --------- .....- - - - - _ ...__...... -.....
- --
ANO
HAVl
you RF.CENEDANY U[II/(fiTS UNDER A rJrl:OIC.Al PLAN
HF"ALTIIIN Sl)rU\NC C?
___ 9
___
____
~ _ _ _ _ _ _ _ _ _ _ w ____ ~ ___ _ _ _ _ _ _ _ _ _ _ _ _ . . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ _____ - _ .
~_~
_________________ _______
~
St~t(>
______ __ ~ _ ",Zip
H;)ve yO~1 r<:ccived :my mcd il;il) troatmcnt for thp. !;iJmc 0" s.imiL, .. ~ymptoms prior fo this occid(!nt?
Ifye:., list name. iol<lClrcs.s. and phollo of
DYes
docto~I!;1 p~ovidin!l tmatm(ml:
OCr.lli-'1\ 110111
I\dcrc~s ,
01111= HIRED
Phone
IUCClJPATION
D"Ai"l: HIKcD
AOeres:;, Phone
o
were vou on the jOb workinll when Ule accident occurred?
Yc-,
ONo
·\il~;AUI LII y H<OM-WQKK ~r.CAN
II<IV(; VOLI received <lny benefits undl:r workers' c;ompensation , sQt;;ial ::.c.:uritv.
Per Month $
Aro vou c,'rmntly rmoOivi"t'I ~mcmplovmcr'lt benefits:
Qt allY
waQe Qr SilI.:.(.,. continuutlotl plan?
o
No
o
No
PorWL'ek$
o
YC5
A~ a t05ult of \I0U~ injury, h.we you incurrcn any othl' r ... ;»p(>n~~s, such ilS lr.mspor1<.llion c;;osts or e)Cpens~ for ~ervic(J:S
yOU would havn
perrormod for yours.(01l or your dt:po.,(lc!nls?
o
DNO
These staOOlllonts am trU(! and compllJle to th~ best of my know!ed~c.
x
:-;iC;N/lTunr OF Af'PUCI\N I QI\ I'J\H I N IIl;UIIKDLI\N
- p. (1f'1!jOII w'1)O CO"I(r\tr~ or COIl r'.pi ll'~~r to com1nil a rri.Hlnulnnt in~u r<..lm'..r! ~-JCl b tJl,.rHl'l nt a fc:kITl'/ . ~ni:itw.lj l1.~
tryrm prr:,onrncnl tOI not fTlUl'u 111 ..10 4 yt! ;)Jt. (IO VI1:U!. lUi ":'Oll~O I '.acV) Qr..:l ffl1.t:'"' JUJ' r'tlor-e I it i n, $~IJ . OOO 00.
or I;\ottl, and ';11;111 1)(, ordC'rcd tn nay rc,;hlv\:tlfl ~:; pH'viC ~(! t>y $t:"Cilrm 451101 :hr.: I"" .,mncr. Cr..o~ 0' HI5G .w
ONr)
May 0311 09:58a
Unit&d Wellness Flint
8102337255
AUTHORIZAnON FOR M!;;OICAL INFORMATION
TI-IIS AUTHORIZATION OR PHO'fOCOPV HEREOF. WILL AU'fHORIZE A PHYSICIAN, I-IOSPIl'AL., CLINIC, O~
O·ftiER MEDICAL INSTITUl'tON TO FURNISH ALL INt-ORMATION YOu MAY HAVE:; f'CcGAROING MV CONOITION
W\-III.= UNDER YOUR OBSERVAnON OR TREAT MCNT, INCLUOING THe HISTORY OBTAINED, X-RAY AND
F't-IYSICA!. FINDINCS DIAGNOSIS ANC>PROGNO$IS. YOU ARe AEQUIRE;D10 PROVIOI;: n·lls INFORMATION
IN ACCO~bANCr. WITH THr: MICHiC"..AN MOTon VI::HIClF NO-FAULT INS\)RANCE LAW, P.A. 294 OF THE
PUBUC ACTS OF 1912.
x
01496~{(6-,~1
G/GNAnil~1:. O":APPI_ICANT-OR PARI;:N r IGUARDIAN
DATI:
CLAlI\rf\lUM~=H
AUTHORIZATION FOR WAGE AND SALARY INFORMATION
11"11$ AUlliORI7ArlCN OR PHCYrOCOPY HERcOI-. WILL Al)lttQRIZE YOU TO rlJRNlSH ALL INrORMA'I'ION
YOU MAY HAVE RCGARDINC MY WAGF.S OR SI\u\RY WHILE EMPLOYED BY YOU. YOU ARE. RH)UIRED
TO PROVIDE THIS INFORMATION IN ACCORDANCe WITH THE MICHIGAN MOTOfot VEHICll:: No..FAUI.T
I/IISU~ANCC LAW. P A 2!1'1 OF THE' PURLIC ACTS
01- 1972.
x
SIGNI\ I UFfI: OF AI'PuCiWi" OR 1·'AI~t.NT/GUA~lJJAIij
0149~76-:"91
UAI~
-CCAIM NUMBER
p.?
TRANSPORTATION EXPENSE LOG
Name:
DOl:
Case No.:
ROUND TR!P
-
DATE
FROM
TO
MILES
,
.
AFFIDAVIT OF ATTENDANT CARE SERVICES PERFORMED
Name of Insured:
Claim #:
Service Provider’s Name:
Date of Incident:
Describe specifically what attendant care services were provided:
A.
B.
C.
D.
E.
F.
Assistance with Hygiene
Grooming
Bathing
Toileting
Transferring/Positioning
Physical Therapy Oversight
G. Eating
H. Meal Preparation
I. Medication Management
J. Care of Health Equipment
K. Management of Finances
L. Wound Care
M.
N.
O.
P.
Q.
Safety Supervision
________________
________________
________________
________________
On the following calendar, please indicate: (a) the services by letter; (b) the dates on which those
services were performed; and (c) the number of hours required for performance of those services for
each date.
Month:
1
2
3
4
5
Hours:
Hours:
Hours:
Hours:
Hours:
8
9
10
11
Hours:
15
Hours:
16
Hours:
17
Hours:
22
Hours:
23
Hours:
29
Hours:
Total hours:
6
7
Hours:
Hours:
12
13
14
Hours:
18
Hours:
19
Hours:
20
Hours:
21
Hours:
24
Hours:
25
Hours:
26
Hours:
27
Hours:
28
Hours:
30
Hours:
31
Hours:
Hours:
Hours:
Hours:
Hours:
Hours:
Charge per hour:
Total Due:
Have you provided services prior to the accident?
I expect to be paid for all services provided.
I declare the above information to be true and accurate and above services were performed as indicated.
________________________________
(signature of party performing services)
(date)
_________________________________
(signature of insured)
(date)

Similar documents