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Please submit as much information as possible

If you were directed to this website by your healthcare provider, it is because you were recently treated because of injuries sustained in an automobile accident, work related accident, or other accident. The registration staff of your treating facility does not have sufficient information to bill the proper insurance. Required fields are marked with an asterisk (*) symbol.

Please understand that ultimately you are responsible for providing this information so that the correct insurance can be billed. The purpose of this site is simply to provide a user friendly and convenient way to provide your treating facility this information.

To read more about the policies with this form click here.

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With Confidence

If you’re considering ACI, the Claims Performance Snapshot is the perfect place to start. It lets us show you the potential revenue hiding in your complex claims — without commitment — so you can see the value ACI brings before making any decisions.

FREE Claims Performance Review