• ACCIDENT QUESTIONNAIRE

  • Date of Service:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dear Member:
    Our review process indicates this patient may have received healthcare services related to an accident. So we may evaluate our responsibility, please complete, sign and return this form within five days of receipt. If we do not receive this information, we may have to deny your claims. If you have previously completed a form for this accident, please   and update.

  • Was the injury or illness:
  • Date of the injury or illness:
     - -
    2 digit month, 2 digit day, 4 digit year

  • If you checked "Auto/Motorcycle Accident" or "Other Accident," please answer the following:

  • Did another person cause this accident?
  • If auto or motorcycle related, was the patient wearing a seatbelt?
  • A helmet?

  • If auto or motorcycle related, was the patient the driver  or a passenger ?

  • If you checked "Work Related," please answer the following:

  • Have you filed a Workers' Compensation claim?
  • Has the employer or the workers' compensation carrier accepted or denied liability?

  • I agree that the above information is correct, and I will not settle a claim before contacting the Subrogation / Workers' Compensation Department of BlueCross BlueShield of South Carolina.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • OTHER HEALTH/DENTAL COVERAGE QUESTIONNAIRE

  • Your contract contains a Coordination of Benefits (COB) provision to ensure we provide correct benefits on claims for members with more than one health/dental coverage plan.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do you or any dependents have any other group health, dental or Medicare coverage?

  • IF NO, PLEASE SIGN, DATE AND RETURN THIS FORM OR CALL US AT OUR COB HOTLINE (800-931-3401) AND WE WILL PROCESS THIS INFORMATION IMMEDIATELY. IF YOU ANSWERED YES, PLEASE PROCEED TO QUESTION #2.

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 2. Please list the family members covered by the other policy and the type of coverage you have.
    Rows

  • For additional family members, attach a separate sheet with the information.

    * If you checked Medicare, answer question #7 on page 2.

  • Other Policyholder's Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • If policy is now terminated, please give termination date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECTION PERTAINS TO MEDICARE COVERAGE ONLY

  • 9. Are you actively working?
  • Start Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 10. Are you or any family members covered by Medicare?

  • If No, please sign and date below. If Yes, please complete the information below.

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare
  • Date of First Dialysis:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Part A Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Reason for Medicare
  • Date of First Dialysis:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: