MEDICAL EXPENSE CERTIFICATE Sample Clauses
The Medical Expense Certificate clause establishes the requirement for a formal document verifying the incurrence of medical expenses. Typically, this certificate must be provided by a licensed medical professional or institution and is used to substantiate claims for reimbursement or insurance coverage. By mandating such documentation, the clause ensures that only legitimate and verifiable medical costs are considered, thereby preventing fraudulent claims and ensuring proper allocation of benefits.
MEDICAL EXPENSE CERTIFICATE. TO BE COMPLETED BY INJURED PARTY OR, IF A MINOR, BY THE MINOR’S PARENT OR GUARDIAN
1) Injured party’s name: First _ _ Middle Last Address: Gender: M F Date of Birth: / _/ Last five digits of SSN: Home Phone: _ Work Phone: Cell Phone: E-mail Address:
2) If injured party is a minor, the minor’s parent or legal guardian should complete the following: Name of Parent (or Legal Guardian): Address: Home Phone: Work Phone: Cell Phone: E-mail Address:
3) Date of occurrence:
4) School where occurrence happened: School District where occurrence happened:
5) Statement of Facts: Tell in your own words exactly what happened. Please attach a separate page if necessary. List of witnesses to occurrence (if there are additional witnesses, please list on a separate page and attach): Name of Witness: Witness Address/Phone: Name of Witness: Witness Address/Phone:
6) Description of Injury:
7) Is treatment complete? Yes No
MEDICAL EXPENSE CERTIFICATE. TO BE COMPLETED BY INJURED PARTY OR, IF A MINOR, BY THE MINOR’S PARENT OR GUARDIAN
1) Injured Party’s Name: First Middle Init. Last Gender: Male Female Address: Date of Birth: