Motor Vehicle Accident (MVA) and Third-Party Billing

You will receive an accident questionnaire to be completed. As a courtesy, we will submit the claim to the insurance carrier provided on the form. It is your responsibility to seek reimbursement from them. If the questionnaire is not returned or completed and/or we receive a denial on your claim, you will be responsible for payment in full.

These policies help the office provide quality care to our valued patients.
If you have any questions or need clarification of any of the above policies, please feel free to contact us.

I agree to abide by the policies of the office and understand that if I do not, I may be asked to seek care elsewhere.

Acknowledgement Signature Required on Demographic Form.

East Lincoln Family Health Professionals, PC. RESERVES THE RIGHT TO CHANGE AND/OR MODIFY THE INFORMATION ON THIS SITE AT ANY TIME.

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Motor Vehicle Accident (MVA) and Third-Party Billing

Same Day Services Available!

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