Automobile Accident


Today’s Date:

12455 Ridgedale Drive, Ste 203 Minnetonka, MN 55305


2822 W 43rd St, Ste 100

Minneapolis, MN 55410

Full Name:

Date of Birth:


City: State: Zip:


Secondary Phone:

How were you referred to our clinic:

Date and Time of Accident/Injury: / / : AM PM

Policy Number:

Medical Claim Number: (Not Bodily Claim # - these are different)

Your Auto Insurance Company: (not the other driver)

Are you the policy holder? Yes No If no, Then the name of the policy holder:

Claim Adjuster:

Contact Info:

Medical Claim Billing Address:

Medical Claim Fax Number:

Have you retained an attorney? Yes No Not yet

Name of Attorney: Phone:



Charges incurred for your care will be filed with your delegated worker’s compensation company. Each insurance company has their own rules, regulations, limits, and procedures and we will work with your insurance company to try and secure coverage for the care you need. However, we CANNOT guarantee payment. If your account is not settled in- full through your insurance within 90 days following the completion of your treatment, the remaining balance will become the patient’s responsibility. At that point we can help to set up a monthly payment plan in order to settle your account balance.

I have read, understand, and agree to the financial policy of SuNu Wellness Ce Inc.r as stated above.

Name (Print):

Signature (Required):