Work Injury / MVA

Claim Information Form

First Name *

Last Name *

Mobile Number *

Email Address *

Is this related to a work injury or motor vehicle accident? (choose at least one) *

Work injuryMotor vehicle accident

Date of injury?

(within 48 hours approval not required)

Have you notified your workplace about your injury? *

YesNo

Has a claim been made for this injury? *

YesNo

Has a personal injury claim been lodged for this injury? *

YesNo

Is your employer/insurance company aware you are having scans done? *

YesNo

Insurer Information

Insurance Company *

Your Claim Number *

Employer Information

Company Name *

Company Address *

Contact Name

Phone *

Please upload your approval letter or any other documents if available

Browse

Please upload your request form (for appointments only)

Browse

I, *Full name

authorise full disclosure of all information relating to my examination (including xrays) to my employer/insurance company as part of my workers compensation/MVA claim.

Synergy Radiology will place my account on hold for 14 days should I not have the claim number and insurance details or pre-approval at the time of service. However, after such time I understand that the invoice will be claimed through Medicare (for eligible services only).

I also understand that should liability of this account be denied by my employer/insurance company that payment for my examination will become my responsibility if not Medicare eligible.

Signature *

Draw signature|Type signatureClear

Date of signing *

Save and Complete Later