Thanks for letting us know!

We appreciate you taking a moment to confirm receipt of our message!

If you have any questions at all about your case please do feel free to call us at 1-877-678-0935. Our Claimant Services team would be happy to assist you.

But wait! Before you go….

If you’ve had a recent medical treatment or visit with a medical professional, tell us about it!

And if your contact information has changed (for instance, a new email address, phone number, home address, or preferred alternate contact) we’d love it if you could update your info!

HAVE AN UPDATE REGARDING YOUR MEDICAL TREATMENT?

If you’re an existing client and have updated information about your medical treatment, please let us know. If we have any questions for you, a member of the Client Services team will be in touch with you directly.

"*" indicates required fields

First Name*

Last Name*

If your current email is not shown here, please enter your email address.

Phone*

If the best phone number to reach you is not shown, please enter it here

Address*

Please type your full address here

Doctor's Name*

Name of the treating medical professional

Doctor's Street Address*

Address of the treating medical professional's office

Doctor's City*

City/town of the treating medical professional's office

Doctor's Zip Code*

Zip code of the treating medical professional's office

Doctor's Phone*

Phone number for the treating medical professional's office

Date of Visit*

Please enter the date of your visit with this medical professional

Reason for Visit*

This field is for validation purposes and should be left unchanged.

UPDATE YOUR CONTACT INFORMATION

If you’re an existing client and have changed phones, addresses, emails, or other important contact details, please let us know using this form. Client Services will be in touch to confirm your details directly. If the info you see here is not correct, please update it!

"*" indicates required fields

Full Name*

Date of Birth*

Best Email Address to Use

If you have an email address, please make sure we have the correct / most current one!

Best Phone # to Reach You*

Alternate Phone (if available)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Preferred Alternate Contact Person

Please enter the name & phone number of a trusted friend or family member who we can contact if we lose touch with you.

Name

This field is for validation purposes and should be left unchanged.

Thanks for letting us know!

HAVE AN UPDATE REGARDING YOUR MEDICAL TREATMENT?

UPDATE YOUR CONTACT INFORMATION

See What Our Clients Are Saying!