Medical Bill Details "*" indicates required fields Step 1 of 4 25% Name* First Last Street* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipCode* Email* Phone*ConsentBy submitting this form and checking this box, I am agreeing to receive text messages from Crown Administrators and business partners. I provide my signature expressly consenting to recurring contact from Crown Administrators or its business partners at the number I provided regarding products or services via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I understand that I can revoke this consent at any time. Terms & conditions/privacy policy apply (https://freedomnegotiators.com/privacy-policy/). Consent to communictions HIPAA PRIVACYPlease provide the following information for our HIPAA Privacy Authorization Form. This form is required before we can speak with your healthcare provider(s).What is your relationship to the patient?*Examples: Self, Mother, Father, Guardian HIPAA In Force Until*The HIPAA agreement will be in force (effective) until the date or event you specify. Which would you prefer? Choose an end date Specify and event HIPAA In Force Until Date*Your HIPAA Authorization will be in effect until this date MM slash DD slash YYYY HIPAA In Force Until event* Authorized Provider 1*Please provide name, address, and phone number of provider related to your medical bill. Authorized Provider 2Please provide name, address, and phone number of provider related to your medical bill. Effective Period*Specify the authorization for release of information covers the period of healthcare services by date range or an event. all past, present, and future periods Date Range Effective Start Date MM slash DD slash YYYY Effective End Date MM slash DD slash YYYY Extent of Authorization* I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) I authorize the release of my complete health records, with the exception of the following information HIPAA Release Exclusions Mental health records Alcohol/drug abuse treatment Communicable diseases (including HIV & AIDS) Other (please specify) Select AllHIPAA Authorization Other FAMILY INFORMATIONPatient InformationPatient First Name* Patient Last Name* Patient Birthdate* MM slash DD slash YYYY Asset and Tax InformationIncome Tax Filing Status*JointlySeparatelySingleNumber of Dependents*Please enter a number less than or equal to 10.Member's Occupation* Spouse's Occupation Prior Year Gross Household Income*Your household's gross annual income. Click HERE for the definition of Gross Income.Prior Year Adjusted Household Income*Your household's adjusted annual income. Click HERE for the definition of Adjusted Income.How much can you commit?*How much can you commit to settling your balance?HiddenPlaceHolder Other InformationMotor Vehicle Accident?*NoYesWork Accident?*NoYesOther Forms of Coverage?*NoYesHiddenPlaceHolder Carrier Carrier Phone Number Group Number Member/Subscriber ID Brief Description of the Incident/NotesPlease provide any information that might help our negotiations team. Almost Done!!When you click the Next button we will present your Freedom Negotiators Client Agreement for your electronic signature. After you have completed the client agreement, you will be prompted to pay your processing fee using PayPal. You can use an existing PayPal account or a credit card. We will also send you an email with the subject Freedom Negotiators Email Confirmation. Please click the button in the email to confirm you have requested our assistance. Confirmation helps email delivery to your e-mailbox.EmailThis field is for validation purposes and should be left unchanged.
