New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 3 - AUTOMOBILE INSURANCE
Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS
Appendix A
Universal Citation: NJ Admin Code A
Current through Register Vol. 56, No. 6, March 18,
2024
Notification of Commencement of Medical Treatment
(to be filed with insurer)
| Name, address and phone number of Treating Health Care Provider: | |
| ............................................................................. | |
| ............................................................................. | |
| Fax Number (optional) ....................................................... | |
| Name and address of patient: | Name and address of insured: (if |
| different) | |
| ...................................... | ...................................... |
| ...................................... | ...................................... |
| ...................................... | ...................................... |
| ...................................... | ...................................... |
| Insurer Name: .............................................................. | |
| Insurer Address: | |
| ............................................................................. | |
| Policy No. .................................................................. | |
| Date of accident/injury: ................................................... | |
| Date of first treatment: ................................................... |
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