Patient Information Form

RevClaims has teamed up with your healthcare provider to help gather information about your accident. As a service to you, your healthcare provider has chosen RevClaims to assist in determining availability and filing for any insurance benefits to which you may be entitled as a result of your accident or injury. RevClaims will obtain details about your accident or injury and all insurance information for anyone involved. Your medical provider and RevClaims will use this information to help coordinate the benefits available to pay the bills associated with treatment for your injury. This service is free to you, the patient, and helps you avoid personal responsibility for medical bills which may be covered by insurance.

RevClaims is standing by to help and welcomes any questions you may have. You can contact RevClaims toll free at (877)653-1721 or complete our our patient questionnaire below.

Click here to read our FAQ with answers to common patient questions.

Section A: General Information

Please review this form carefully and complete the applicable fields.

Fields marked with an asterisk (*) are required.
Patient Name
Account/Reference Number
Date of Birth
Date of Service (YYYY-MM-DD)
Date of Accident (YYYY-MM-DD)
Please describe the accident:
Location and county of accident
Are you pursuing a liability claim against anyone? Yes    No
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