Potential Injury/Accident Report

Potential Injury/Accident Report

We are evaluating a request for payment of services rendered indicating a potential injury. In order to proceed with the processing of the payment of these services we need your assistance with the below details.
Member Name*

First NameLast Name
Date of Injury/Accident*

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Claim Number (Optional)
Accident Details

Please provide the following information
Full description of the injury/accident, to include where and how it happened.*
Address where injury / accident occurred.*

Street Address

Street Address Line 2

CityState

Zip Code
Is this related to (check one):*

Auto AccicentWorkOther
Was a police report created as a result of this injury/accident?*

YesNo
Do you have a copy of the police report?*

YesNo
If possible, provide a copy of the completed police report.

Cancelof
Please provide the name of your automobile insurance company.*
Please provide the policy # of your automobile insurance.*
Please provide the address of your automobile insurance company.*

Street Address

CityState

Zip Code
Please mark one of the following:

There was no other party involved.I DO NOT INTEND to make a claim against the other party.I INTEND to make a claim against the other party. From any proceedings arising from such a claim, I will reimburse my employer health plan, in full, without any offsets, reductions or contributions of any kind, all monies paid on my behalf for expenses incurred as a result of this third-party accident.I INTEND to make a claim against the other party and do not wish to make a claim for medical coverage under my employer health plan at this time.
Do you have an attorney?*

YESNO
Name of your attorney?*

First NameLast Name
Phone number of your attorney*
Please enter a valid phone number.Format: (000) 000-0000.
Address of your attorney?

Street Address

CityState

Zip Code
Do you need to add another person you believe are responsible for this injury?*

YESNO
Name of the person you believe is responsible for the injuries.*

First NameLast Name
Address of the person you believe is are responsible for the injuries.

Street Address

CityState

Zip Code
Do you need to add another person you believe are responsible for this injury?*

YESNO
Name the person(s) you believe is/are responsible for the injuries.*

First NameLast Name
Address of the person(s) you believe is/are responsible for the injuries.*

Street Address

CityState

Zip Code
Do you need to add another person you believe are responsible for this injury?*

YESNO
Name the person(s) you believe is/are responsible for the injuries.*

First NameLast Name
Address of the person(s) you believe is/are responsible for the injuries.*

Street Address

CityState

Zip Code
Name of the insurance company of the person(s) responsible.
Phone Number of the insurance company of the person(s) responsible.
Please enter a valid phone number.Format: (000) 000-0000.
Address of the insurance company of the person(s) responsible.

Street Address

CityState

Zip Code
Please complete the form, sign, date and submit to Performance Health.

Please understand that until this information is received, the claim(s) will remain denied and will not be reviewed for payment.

If any PPO discounts are applicable to these expenses, failure to respond to this request promptly may put the discount in jeopardy. If discounts are deemed invalid due to delay in payment for untimely responses to requests for additional information, the amount of the discount may become the member's responsibility.
Please verify that you are human*
Date

MonthDayYear
Date
Signature
Performance Health

PO Box 450978 | Westlake, OH 44145 | 877-585-8480
Should be Empty:

Potential Injury/Accident Report

Accident Details