|
PARADIGM MEDICAL SERVICES, INC. REQUEST FOR MEDICAL COST MANAGEMENT
SERVICES |
Requesting Party
Contact:
Company Address:
Phone:
Fax:
Email:
Date Submitted: __ / __ /
____ Date of Accident: __ / __ / ____
MM DD
YYYY MM
DD YYYY
Claimant/Patient Name:
Social Security #:
Insured/Employer:
Your File Number:
Insurance Company:
Can payment of agreed audit
be paid within 10 days?
Yes q No q
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22516 Aldine
Westfield • Spring, TX 77373 • Phone (281) 350-5662 • Fax: (281) 350-5772 info@paradigmmedservice.com |