Accident & Health - First Notice of Claim

Accident & Health - First Notice of Claim Form
Provident Claims Services, Inc.

PO Box 38295

Pittsburgh, PA 15238-8295

Toll-Free: 800.478.1752 | Fax: 412.963.0148

Email: claims@providentclaims.com

Business Hours: 8:30 AM to 5 PM

Please note, this document could take up to 15+ minutes to complete. If you wish to start filling it out now, you can always press "Save & Continue Later" at the bottom of this form to complete and submit at a later time.
Review our Important Notice Regarding Fraud before continuing:
Full Name*
Date of Birth*

MonthDayYear
Social Security Number*
Address*
City*
State*
Zip Code*
Email*
example@gmail.com
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your regular, full time occupation?*
This is the occupation for which you make a living of. If you are student then put "Student," if you are unemployed then put "Unemployed," if you are a homemaker then put "Homemaker," etc.
Employed By (Name of Company)
Employer’s Address
Employer’s City
Employer’s State
Employer’s Zip Code
Employer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
File Upload

Please enclose pre-injury pay stub or the prior years W2 or Schedule C (if self-employed). You may also include a discharge summary from your hospital, related medical records, Workers' Compensation documentation related to this claim, incident report, or other related documents that could support your claim.
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Wages/Earnings Hourly*
If no wages/earnings enter 0.
Wages/Earnings Weekly*
If no wages/earnings enter 0.
Date of Hire (Full Time Occupation)

MonthDayYear
Time of Accident

Hour Minutes
AMPM
Date of Accident*

MonthDayYear
Place of Accident*
Date Last Worked

MonthDayYear
What is your injury or illness?*

0/30
How did it happen?*

0/50
Name of Treating Physician
Full Address of Treating Physician
Please input Street, City, State and Zip Code.
Phone Number of Treating Physician
Please enter a valid phone number.Format: Phone (000) 000-0000.
Fax Number of Treating Physician
Please enter a valid fax number.Format: Fax (000) 000-0000.
Name of Hospital
Full Address of Hospital
Please input Street, City, State and Zip Code.
Phone Number of Hospital
Please enter a valid phone number.Format: Phone (000) 000-0000.
Fax Number of Hospital
Please enter a valid fax number.Format: Fax (000) 000-0000.
YesNoUnknown at this time
YesNo
1a. I was totally disabled FROM:

MonthDayYear
1b. I was totally disabled TO:

MonthDayYear
2a. I was partially disabled FROM:

MonthDayYear
2b. I was partially disabled TO:

MonthDayYear
Date you have or are expected to return to work:*

MonthDayYear
I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND COMPLETE ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF.

I hereby authorize any physician, hospital, insurer, governmental agency, other organization or person having any records, data or other information concerning me to furnish such records, data or information as may be requested by Provident or its duly authorized representative. I understand that in executing this authorization I waive the right for such information to be privileged. A copy of this authorization shall be considered as effective and valid as the original.
Date*

MonthDayYear
Claimant Signature*
THE AUTHORIZATION INCLUDED WITH THIS FORM MUST BE SIGNED AND SUBMITTED TO PROVIDENT CLAIMS SERVICES, INC.

A SMALL SECTION OF THIS FORM MUST BE COMPLETED BY AN AUTHORIZED REPRESENTATIVE OF THE FIRE DEPARTMENT OR MUNICIPALITY. THE INDIVIDUAL COMPLETING THIS SECTION MUST BE AN OFFICIAL OF THE NAMED INSURED AND MAY NOT BE THE CLAIMANT OR A MEMBER OF THE CLAIMANT'S IMMEDIATE FAMILY. PLEASE PROVIDE US AN AUTHORIZED OFFICER'S CONTACT INFORMATION IN THE FIELDS BELOW.

PROVIDENT WILL SEND THIS FORM TO THE OFFICER LISTED BELOW SO THEY CAN REVIEW, AUTHORIZE, AND SIGN THIS FIRST NOTICE OF CLAIM FOR COMPLETION. YOU WILL RECIEVE A FULLY EXECUTED COPY OF THE FORM FOR YOUR RECORDS AFTER THE OFFICER COMPLETES IT.
Authorized Officer's Full Name*
THIS CANNOT BE THE CLAIMANT'S NAME.
Authorized Officer's Title*
THIS CANNOT BE THE CLAIMANT'S TITLE.
Name of Fire/Rescue/Ambulance Company/District or Relief Association *
Municipality*
Authorized Officer's Email*
THIS CANNOT BE THE CLAIMANT'S EMAIL.
Authorized Officer's Main Phone Number*
THIS CANNOT BE THE CLAIMANT'S PHONE NUMBER.Format: (000) 000-0000.
See Important Notice Regarding Fraud in the PDF at the beginning of this form.

Failure to complete this form in its entirety may result in a delay of processing your claim.

NOTE: This authorization allows the ___________ to release all information pertaining to an injury that occurred on or about (Insert Date of Loss/Diagnosis) to Provident Claims Services, Inc. You are not required to sign the authorization, but if you do not, we may not be able to evaluate or administer your claim(s). Please sign below to submit this authorization to Provident Claims Services, Inc.

MonthDayYear
Date of Loss/Diagnosis
Authorization
I authorize any health care provider including, but not limited to, any health care professional, hospital, clinic, laboratory, pharmacy or other medically related facility or service; health plan; rehabilitation professional; vocational evaluator; insurance company; reinsurer; insurance service provider; third party administrator; producer; the Medical Information Bureau; GENEX Services, Inc.; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability Income Record System; government organization; and employer that has information about my health, financial or credit history, earnings, employment history, or other insurance claims and benefits including Social Security benefits, to disclose any and all of this information to persons who administer claims for Provident. Information about my health may relate to any disorder of the immune system including, but not limited to, HIV and AIDS; use of drugs and alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes.

I understand that any information Provident obtains pursuant to this authorization will be used to evaluate and administer my claim(s) for benefits, including any assistance in my return to work. I further understand that the information is subject to redisclosure and might not be protected by certain federal regulations governing the privacy of health information.

This authorization is valid for two (2) years from the date below, or the duration of my claim, whichever is shorter. A photographic or electronic copy of this authorization is as valid as the original. I understand I am entitled to receive a copy of this authorization.

I may revoke this authorization in writing at any time except to the extent Provident has relied on the authorization prior to notice of revocation or has a legal right to contest a claim under the policy or the policy itself. I understand if I revoke this authorization, Provident may not be able to evaluate or administer my claim(s) and this may be the basis for denying my claim(s). I may revoke this authorization by sending written notice to the address above. I understand if I do not sign this authorization or if I alter its content in any way, Provident may not be able to evaluate or administer my claim(s) and this may be the basis for denying my claim(s).
Signature*
Date Signed*

MonthDayYear
Full Name*
Social Security Number*
I signed on behalf of the claimant as (indicate relationship here).
Relationship
File Upload - If Power of Attorney Designee, Guardian, or Conservator, please attach a copy of the document(s) granting authority.

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Direct Deposit Authorization Form
Authorization Agreement (ACH Direct Deposit Only). By signing below, I (the "Receiver") authorize Provident Claims Services, Inc. (PCS) (the "Originator") to initiate Automated Clearing House (ACH) credit entries (direct deposits) to the deposit account identified below (the "Account"). This authorization is limited to the direct deposit of claim payment proceeds and any permissible correcting entries related to those deposits.
By checking this box, I acknowledge and agree that this authorization permits PCS to initiate ACH credit entries (direct deposits) ONLY. No ACH debit entries will be initiated to my account under this authorization.
This form is to be used for PCS direct deposit of funds only.
New AuthorizationChange ExistingDiscontinue Service
Receiver SS# or FEIN#:*
Receiver Name:*
Start Date:*

MonthDayYear
Receiver Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
On behalf of (claimant, minor, etc.)
Receiver Email Address:*
example@gmail.com
No Liability for Bank Delays/Incorrect Information. I understand the Originator is not responsible for delays or losses caused by incorrect or incomplete information I provide, actions or errors by my financial institution, or events outside the Originator's reasonable control.
Compliance and Dispute Cooperation. Entries initiated under this authorization will comply with the Nacha Operating Rules and applicable U.S. law. I certify that I am an authorized signer or owner of the Account and authorize my financial institution to provide information needed to resolve any entry, return, or notice of change related to this authorization.
Revocation/Changes. This authorization will remain in effect until the Originator receives my written notice to change or revoke it. Any change or revocation request must be received at least five (5) banking days before the next scheduled deposit date to allow a reasonable opportunity to act.
Notice of Issues. I will promptly review my Account activity and notify PCS if a direct deposit has not been received or if an amount is incorrect. To the extent permitted by law and the Nacha Rules, claims relating to an unauthorized or erroneous entry are subject to applicable reporting timeframes.
Correction, Reversal, and Adjustments for Errors. If an entry is made in error (including an incorrect amount, duplicate entry, wrong account, or wrong effective date), I authorize the Originator to initiate a correcting entry or reversal as permitted by the Nacha Operating Rules and applicable law. The Originator will make reasonable efforts to notify me of any reversal and the reason for it as required by the Nacha Rules.
Account Verification and Receipt of Entries. I authorize the Originator and its financial institution to verify my Account information, including by initiating one or more prenotification (zero-dollar) entries or other commercially reasonable verification methods, and to deposit funds to the Account in accordance with this authorization.
Primary Account Information
Name of Financial Institution:*
CheckingSavings
PersonalCommercial
Routing Number:*
Account Number:*
Privacy and Data Use Notice. PCS will use the banking and personal information provided on this form solely for the purpose of initiating and administering ACH direct deposit transactions and for related operational, legal, and compliance purposes. Such information will be maintained and safeguarded in accordance with applicable federal and state privacy and data security laws, including the Gramm-Leach-Bliley Act (GLBA), and will not be disclosed to third parties except as necessary to process ACH transactions, comply with law, or as otherwise permitted by applicable regulations.
Please upload a voided check here.

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Signature
Authorized Signature (Primary):*
Date:*

MonthDayYear
Authorized Signature (Joint):
Date:

MonthDayYear
Please verify that you are human*
Should be Empty:

Accident & Health - First Notice of Claim Form

Authorization

Authorization for Release of Protected Health Information

Direct Deposit Authorization Form

Primary Account Information

Signature