Lung Transplant Medical Bills Aid Inquiry Form

Although there is no cure for Pulmonary Hypertension, a lung transplant can control the disease, extending patients lives and improving their quality of life. Unfortunately many of these treatments are very costly and insurance may not cover all of them. If you or a loved one has pulmonary hypertension you or they may be entitled to a substantial compensation package. Your information will be reviewed to determine if you are eligible to file for a claim. Your information will be kept strictly confidential and used solely to evaluate your claim. Please review our terms and conditions.

Title:

First Name:

  M. I.

 

 Last Name:

 Address:

 City:

 State:

 Zip Code:

 Phone Number (day):

 Phone Number (eve):

Email Address 

 If this inquiry is not for yourself, please tell us the name of the person? (otherwise skip):

Title:

First Name:

M. I.

Last Name:

What is the Injured's relationship to you?:

Injured's Date of Birth?
(ie mm/dd/19yy) 

 Do you or they have pulmonary hypertension?:

Dates of diagnosis?:

Did you or they take any diet drugs?:

 Yes No

Which ones?:

 Are you or they considering a lung transplant?

Please briefly describe your concern
 
 I understand that submitting this form does not create a doctor-patient or attorney-client relationship:Agree


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