Settlement Information Request - English

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Patient's Information

ServiceLine

Patient's Name*

First Name

Last Name

Reference Number*

This number, typically 3 or 4 letters followed by 6 numbers, can be found on the patient’s lien in bold font above the patient’s name, for example, REF #: TMC123456. If you don’t know the Reference number, please call 706-660-5536.

Hospital Where Patient Was Treated

Accident Date*

Offer To Settle Medical Charges* $

Patient is the one requesting reduction*

Yes No

Aspirion needs contact information regarding the person who is making the request, so we can send you a written reduction request response by mail or facsimile.

Patient's Address

Address Line 1

Address Line 2

City

State

ZIP Code

Patient's Phone Number

Patient's Email

Requestor's Information

Requestor's Name*

First Name

Last Name

Requestor's Role*

Attorney Adjuster

Lawfirm/Company Name

Lawfirm/Company Address

Address Line 1

Address Line 2

City

State

ZIP Code

Lawfirm/Company Phone Number

Lawfirm/Company Fax Number

Lawfirm/Company Email

Fee Amounts

Contractual Attorney's Fees $

Attorney's Fee After Reduction $

Expenses $

Patient's Information

Requestor's Information

Settlement Offer Information

Fee Amounts

Medical Bills