Emergency Room Bill Purchase Program

Patient Information

First Name Last Name

Address City

State Pick one from list Alabama Alaska Arizona Arkansas British Virgin Islands California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Mariana Islands Mariana Islands (Pacific) Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont VI U.S. Virgin Islands Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip

Phone1 Phone 2

E-mail address

Date of Accident Date of Birth / / (ex: 1971)

Type of Accident

Type of Treatment

Treatment Date(s)

Total Lien Balance $

Facility Information

Facility Name Contact

Address City

State Pick one from list Alabama Alaska Arizona Arkansas British Virgin Islands California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Mariana Islands Mariana Islands (Pacific) Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont VI U.S. Virgin Islands Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip

Phone1 Fax

E-mail address

Attorney Information for Patient (only complete if Patient has attorney)

First Name Last Name

Address City

State Pick one from list Alabama Alaska Arizona Arkansas British Virgin Islands California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Mariana Islands Mariana Islands (Pacific) Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont VI U.S. Virgin Islands Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip

Phone1 Fax

E-mail address

Paralegal Name