For Caregivers
Care Book: Medical and Insurance Information
Last Updated:
Emergency MEDICAL AND INSURANCE INFORMATION
for ________________________
NON - BRAIN RELATED
Doctor__________________________________ Phone_____________
Address____________________________________________________
Hospital_________________________________ Phone_____________
BRAIN RELATED INJURY
Doctor__________________________________ Phone_____________
Address____________________________________________________
Hospital_________________________________ Phone_____________
Insurance Company:___________________________________
Patient Name: ___________________________________
Birthdate: ___________________________________
Guardian if applicable___________________________________
Ins. Member: _________________________________________
Employed by _________________________________________
Member # _________________________________________
Group # _________________________________________
Member call: ___________________________
Providers call: ___________________________
List of those having a valid Consent to Treat Form:
You may request to keep one on file with your doctor, family members
and/or friends.
Name______________________________ Phone______________
Name______________________________ Phone______________
Printable Forms
Care Book: Medical & Insurance Information
Karen Moderow is a freelance writer with over ten years experience working in public relations for charitable organizations. As the parent of a son with traumatic brain injury, she has considerable experience dealing with brain injury issues. Her new book, Back Roads Home, chronicles her family’s journey. She is the Director of Content for the Brain Injury Resource Center. www.moderow.us