Report Claim

Patient Full Name*

Names of any other medical providers who may be involved

Names of any hospitals, clinics, nursing homes, etc. that might be involved

Description of what happened and when it happened

Information available regarding the nature of the claim

Upload any written request you might have received either from an attorney, the patient, a family member of the patient’s or any third party

Drop files here or

Name

This field is for validation purposes and should be left unchanged.

CARE is always looking for new agents to add to its network.