Engagement Form – Health & Medicine Law Firm

Step 1

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Alternate Phone Number

Email *

Email

Confirm Email

Driver's License Number *

State Issued *

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.