Create Settlement Request - Aspirion

Patient´s Information

First Name

Last Name

Reference Number

Accident Date

$

Offer to Settle Medical Charges ($)

Requestor´s Information

Patient is Requesting Reduction

First Name

Last Name

Lawfirm/Company Name

Lawfirm/Company Address

Lawfirm/Company City

Lawfirm/Company State

Lawfirm/Company Zipcode

Lawfirm/Company Phone Number

Lawfirm/Company Fax Number

Lawfirm/Company Email

Address

City

State

Zip code

Phone number

Email

Settlement Offer Information

Settlement Reached or Pending

$

Total Settlement/Offer Pending ($)

Liability Insurance is Available

$

Liability Limit Amount ($)

$

Settlement/Offer from Liability ($)

Liability Settlement Date

Liability Insurance Carrier

UM/UIM Coverage Available

$

UM/UIM Limit Amount ($)

$

Settlement Offer from UM/UIM ($)

UM/UIM Settlement Date

Med Pay/PIP Available

$

Med Pay/PIP Available Amount ($)

Med Pay/PIP Disbursed

$

Med Pay/PIP Disbursed Amount ($)

Fee Amounts

$

Contractual Attorney's Fees ($)

$

Attorney's Fee after Reduction ($)

% Reduction

$

Expenses ($)

Medical Bills

Any Other Considerations