Confirmation Of Treatment

Per your conversation with our team, we are sending you this “CONFIRMATION OF TREATMENT (COT)” template based on your completion of medically necessary treatment(s) for injuries sustained from your claim. The COT serves as a confirmed list of facilities and providers you received specialized care from for your accident related injuries. As part of the COT process, we are asking that you fill out the fields below to move forward with the next steps of your claim.

Name(Required)

First Last

Email(Required)

COMPLETION OF CARE(Required)

Yes, I have concluded medical care and have reached Maximum Medical Improvement.

No, I have not concluded care and am still experiencing pain but would still like to move forward with settling my personal injury case.

Treatment Providers(Required)

Provider/s

Name of Provider/Facility	Address	Phone Number	Treatment Date From	Treatment Date To	Actions

There are no Providers.