Motor Vehicle Accident Patient Consent Form
I understand that for all motor vehicle accidents visits it is my responsibility to pay at the time of service. I understand that I will be expected to acknowledge and sign this patient consent form at each MVA visit. I understand that my financial status will be considered “self pay” for all visits regarding my motor vehicle accident.
I understand that Pioneer Physicians Network will not bill my health or auto insurance for my MVA claims. Pioneer Physicians Network will provide an itemized statement upon request to assist you with billing your automobile insurance.
** EXCEPTION RULE **
There are two health insurance groups that PPN can bill directly for MVA per contract and they are United HealthCare and SummaCare. For these insurances, if the patient has an MVA we bill the health insurance.
I agree to provide the following information at each MVA visit:
Address *
Address
Address 1
Address 2
City
State/Province
Zip/Postal
(City, State)
In this accident were you the *
Were you wearing a seatbelt *