N.J. Admin. Code § Tit. 11, ch. 3, subch. 25, app A

Current through Register Vol. 56, No. 12, June 17, 2024

Appendix A

Notification of Commencement of Medical Treatment

(to be filed with insurer)

Name, address and phone number of Treating Health Care Provider:

.............................................................................

.............................................................................

Fax Number (optional) .......................................................

Name and address of patient:	Name and address of insured: (if
different)
......................................	......................................
......................................	......................................
......................................	......................................
......................................	......................................

Insurer Name: ..............................................................

Insurer Address:

.............................................................................

Policy No. ..................................................................

Date of accident/injury: ...................................................

Date of first treatment: ...................................................

N.J. Admin. Code Tit. 11, ch. 3, subch. 25, app A

Amended by R.1998 d.591, effective 12/21/1998 (operative March 22, 1999).
See: 30 New Jersey Register 3202(a), 30 New Jersey Register 4390(b).
Substituted a reference to Treating Health Care Providers for a reference to Treating Medical Providers