• ACCIDENT QUESTIONNAIRE

  • Date of Service:
     - -

  • 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:
     - -

  • 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
     - -
  • 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
     - -
  • 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:
     - -
  • 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:
     - -
  • Effective Date:
     - -
  • If policy is now terminated, please give termination date:
     - -

  • SECTION PERTAINS TO MEDICARE COVERAGE ONLY

  • 9. Are you actively working?
  • Start Date:
     - -
  • 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:
     - -
  • Part A Effective Date:
     - -
  • Part B Effective Date:
     - -
  • Reason for Medicare
  • Date of First Dialysis:
     - -
  • Date of Birth:
     - -
  • Part A Effective Date:
     - -
  • Part B Effective Date:
     - -
  • Reason for Medicare
  • Date of First Dialysis:
     - -
  • Date:
     - -
  • Should be Empty: