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HAVEN CHIROPRACTIC CENTER 301 Columbia Street, Schuylkill Haven, PA 17972 Automobile Accident Information Patient Number (for office use only) Page 1 of 2 PATIENT INFORMATION Name Date of Accident
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How to fill out hcc accident formdoc
How to fill out hcc accident formdoc:
01
Start by entering your personal information, including your full name, address, phone number, and email address.
02
Provide details about the accident, such as the date, time, and location it occurred. Also, describe the circumstances or events leading up to the accident.
03
Indicate any injuries sustained during the accident and provide a detailed description of each injury. If there were no injuries, state "None" or "N/A."
04
If applicable, provide information about any witnesses who were present during the accident. Include their names, contact information, and a brief statement of what they witnessed.
05
If you received medical treatment following the accident, note the name of the healthcare provider, their contact information, and the nature of the treatment received.
06
Describe any damages or property involved in the accident, such as vehicles or other belongings.
07
Sign and date the form to certify that the information provided is accurate and truthful.
Who needs hcc accident formdoc?
01
Individuals involved in accidents that are covered by HCC insurance policies need to fill out the hcc accident formdoc.
02
This form is necessary for both policyholders and any other individuals involved in accidents where HCC insurance is applicable.
03
Employers or organizations that have HCC insurance coverage may also need to fill out this form if one of their employees is involved in an accident.
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