For attorneys Refer a new case orrequest a new case to be opened If you are an attorney’s office representing the injured party, please send your request on your firm’s letterhead, or provide a signed, HIPAA-compliant medical release signed by your client. If available, please also provide a copy of the injured party’s health insurance card. Email to [email protected] or via fax to (901) 380-0692.Injured Party’s Information(Required)First nameLast(Required)Last nameDate of birth(Required)Date of birthDate of initial accident or injury(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Injured party's health plan(Required)Example – Cigna, Aetna, etc.Injured party’s health insurance ID numberCompany funding the health insurance TPANature or description of accidentTypes of injuries sustainedCase contact information(Required)CompanyClaim number(Required)Claim numberCase manager or attorney(Required)Case manager or attorneyPhone(Required)PhoneEmail(Required)EmailFax(Required)FaxEmail(Required) Enter Email Confirm Email For potential follow up, please provide your email(Required) Enter Email Confirm Email CommentsIf you have a question about an existing case, please contact your case representative directly. Please note, Intellivo cannot reprocess or approve healthcare claims for the TPA.CAPTCHA
