CPM Screening Form
Patient Information
Name of Client:
Sex:	Male     Female
Address:
Apt #:
City:
Postal Code:
Phone:	-
Fax:	-
Email:
Date of Birth	Month January Febuary March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Date of Accident or Loss:	Month January Febuary March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2010 2011 2012

 

Insurance Information
Insurance Company:
Adjuster's Name:
Address:
Suite #:
City:
Postal Code:
Phone:	-
Fax:	-
Policy #:
Claim #:
Law Firm / Representative:
Phone:	-
Family Physician:
Physician's Phone:	-

Patients with Extended Insurance Please Note the following: Extended insurance must be used up first. Once extended insurance has been exhausted, CPMM will provide patient with a receipt for treatment received to date. It is the patient’s responsibility to do the following; 1) send this receipt to extended insurer and ask for a statement indicating that this coverage has been exhausted; 2) bring the statement and cheque from their insurer to CPMM. At which point CPMM will assume responsibility to process the remaining claim through patient’s auto insurer.