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Engagement Form
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Step 1
Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell Phone
*
Alternate Phone Number
Email
*
Email
Confirm Email
Driver's License Number
*
State Issued
*
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State where your driver's license was issued.
Date of Birth
*
Referred By
Step 2
Total Amount of Medical Bills
*
Please Note
Bills must be disputed within 30 days of receipt to reserve your rights under consumer laws. Please call us immediately if you bill is due within the next 5 days.
For each medical bill, list the following
Comma separate if more than 1 bill
Hospital / Medical Provider Name
*
Amount of Medical Bill
*
Date of Service
*
Any bill currently in collections?
*
No
Yes
Name of Collection Agency
Comma separate if more than 1.
Urgent Due Date
If there's an urgent due date for any of the items in collections, please input them here.
Step 3
Upload Medical Bills
Click or drag a file to this area to upload.
You can upload multiple files at once using an archive format such as .zip.
Upload Hospital Admissions Contract
Click or drag a file to this area to upload.
You can upload multiple files at once using an archive format such as .zip.
Upload Health Insurance Card
Click or drag a file to this area to upload.
Upload Driver's License
Click or drag a file to this area to upload.
Upload Summary of Benefits
Click or drag a file to this area to upload.
You can upload multiple files at once using an archive format such as .zip.
Upload Health Insurance Policy
Click or drag a file to this area to upload.
You can upload multiple files at once using an archive format such as .zip.
Sign & Review
Signature
*
Clear Signature
Name
Finalize