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Providers
Patients
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- Patient FAQ’s
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Contact

New Client Intake

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REQUEST A LIFE CARE PLAN

Attorneys: Please submit and we will contact you within 24-48 hours.

Download New Client Intake

ATTORNEY INFORMATION

Law Firm *

Attorney Name

Mr.
Ms.

Law Firm Contact Name (if not attorney) *

First

Last

Title

Paralegal
Case Manager
Asst.
Other

State *

Email *

Phone *

Phone Type

Office
Cell

CLIENT INFORMATION

Name *

First

Middle

Last

Client Sir Name

Mr.
Ms.

Language

English
Spanish
Other

Language Other

Phone *

Email *

DOB *

SSN

Address

Address Line 1

City

State

Zip Code

Client Type:

Driver
Passenger
Pedestrian
Cyclist
Other

Client Type Other

Was client employed at time of injury?

Yes
No

CASE INFORMATION

Incident Date *

Police Department

Police / Incident Report

Attached
N/A

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Police Report Number

Number of Claimants *

Is this Workers' Compensation?

Yes
No

Accident *

Rear-End
Sideswipe
Side-Impact
Head-on
T-Bone
Rollover
Slip & Fall/Bodily Injury
Other

Accident Other

Road Type

Highway
Intersection
Parking Lot
Street
Other

Road Type Other

Property Damage?

Total Loss
Repairable

Property Cost

Brief Description *

Has client been involved in a prior accident(s)?

Yes
No

If yes, list incident date(s) and type(s) of injuries sustained in each

Does client have any pre-existing health conditions?

Yes
No

If yes, state the nature of client’s pre-existing conditions

Client Vehicle Year

Client Vehicle Make

Client Vehicle Model

Adverse Vehicle Year

Adverse Vehicle Make

Adverse Vehicle Model

ADVERSE/DEFENDANT INSURANCE INFORMATION

Liability Accepted? *

Yes
No

Policy Limits

Policy/Claim #

Insured Full Name *

First

Middle

Last

Insurance Company

Phone

CLIENT/PLAINTIFF INSURANCE INFORMATION

Type(s) of Coverage/Limits *

UM
UIM
Med-Pay
PIP

Limits Available

Policy/Claim #

Insurance Company

Phone

Is client Medicare or Medicaid insured?

Yes
No

Did client carry private health insurance at the time of incident?

Yes
No

Is client Medicare or Medicaid eligible?

Yes
No

When do you anticipate this claim to settle?

0-2 Months
3-6 Months
7-9 Months
10-12 Months
1-2 Years
2+ Years

TREATMENT INFORMATION

Medical Bills to date (estimate) *

Type of Treatment to date

Ambulance?

Yes
No

Description of Injuries

Hospital?

Yes
No

If yes, Hospital Name

City

State

Date of First Treatment?

Treatment requested *

Physical Therapy
MRI/Imaging
Ortho-Extremity
Ortho-Spine
Pain Management
Neurology
Psychological Evaluation
Initial Medical Evaluation
Other

Other treatment requested

OTHER INFORMATION

Is there any additional information you would like to include that may be helpful?

Old Pueblo Medical Financing, LLC
1101 N. Wilmot Rd., Suite #229
Tucson, AZ 85712

Se habla español.

Office: (520) 829-6140
Fax: (855) 821-3501

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Old Pueblo Medical Financing (OPMF) does not direct care nor make medical or legal decisions. OPMF is not a medical provider nor health insurance carrier. The information contained on this website is for informational purposes and is not to be considered legal advice, an agreement of funding or inclusive of all terms and conditions.

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Old Pueblo Medical Financing, LLC

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Attorneys
Providers
Patients
- Find a Personal Injury Attorney
- Patient FAQ’s
About
Contact