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Emergency Room Charges

Please complete this claim form to request a free case evaluation from a lawyer listed on LawyersAndSettlements.com.

Fields marked * are required.

*Hospital:
(who overcharged you?)

*Describe your complaint:
(briefly describe the damages you have suffered)

*What medical treatment triggered your Emergency Room visit?

*What treatment did you receive at the hospital?

*Date of your hospital visit?

*Were you seen in the same Emergency Room previously?

*Did you have medical insurance which covered your emergency visit?

*If you had insurance, did you receive an Explanation of Benefits (EOB) for your hospital visit?

*What were the hospital’s total charges prior to any discounts or payments?

*What is your share of the hospital's bill:

*Do you feel the hospital’s billed charges were excessive and unfair?

*Do you still maintain hospital billing statements and paperwork from your insurer?

*First name:

*Last name:

*Email address:

*Confirm email address:

*Phone number(s):

*Zip/Postal Code:

Best time & way to contact you:

I would like to be interviewed by a journalist.

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