Submit Information

If you have been contacted by our office, insurance and/or attorney information can be uploaded securely using our online form. You may also download a form and mail it to our office.

Form Download

You can click this link to download a printable Insurance Information Form. The completed form can be returned to our office at:

Medical Account Management, Inc.
P.O. Box 42380
Baltimore, MD 21284-2380

"*" indicates required fields

SUBMITTER INFORMATION

Submitter Name:*

First Last

Submitter Email:*

PATIENT INFORMATION

RE:*

Patient Name:*

Account Number*

Date of Service*

Amount Due:*

INSURANCE INFORMATION

Were you injured on the job?*

If YES, who is your employer:*

If NO, was this related to an automobile accident?*

Yes

Briefly describe how this injury occurred:

Please identify the name of the workers compensation or automobile insurance carrier in the spaces provided below:

Insurance Name

Insurance Adjuster/ Agent

Insurance Address

Date of Accident/ Injury

Insurance Phone Number

Claims Adjuster

Policy Number/ Claim Number

Accident Report Number/ Case Number

Attorney’s Name

Attorney’s Address

* I understand and acknowledge that by clicking SUBMIT the above referenced information will be transmitted via an unsecure email. I understand that as an alternative I may download and mail the above referenced Insurance Information Form.

Name

This field is for validation purposes and should be left unchanged.

Medical Account Management Inc.