hiltonheadorthopedics.com - Patients with Blue Cross Insurance

Subscriber:

Address:

Patient:

Identification No.:

Provider:

Date of Service:

Date

Group Number:

Claim Number:

Claim Amount:

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 check here and update.

Was the injury or illness:

Auto/Motorcycle AccidentWork RelatedOther AccidentNo Accident

Date of the injury or illness:

Date

City/County and State of Injury:

Describe the injury or illness and how it happened:

Names of other family members injured:

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

Did another person cause this accident?

YesNo

If yes, name and address of person causing injury:

Insurance Company of person causing injury:

Policy/Claim #:

Address and Phone #:

Adjuster's Name:

If auto or motorcycle related, was the patient wearing a seatbelt?

YesNo

A helmet?

YesNo

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

Auto Insurance Company of Patient:

Policy/Claim #:

Address and Phone #:

Adjuster's Name:

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

Name and address of patient's employer at the time of injury:

Have you filed a Workers' Compensation claim?

YesNo

If yes, name of Workers' Compensation carrier:

Policy/Claim #:

Adjuster's Name:

Address and Phone #:

Has the employer or the workers' compensation carrier accepted or denied liability?

ACCEPTEDDENIED

Name, address, and telephone number of your attorney (if applicable):

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.

Signature

Date

Telephone Number

Please enter a valid phone number.

	Family Members	Medical	Hospital	Drug	Dental	Medicare
1.
2.
3.
4.
5.

ACCIDENT QUESTIONNAIRE

OTHER HEALTH/DENTAL COVERAGE QUESTIONNAIRE

SECTION PERTAINS TO MEDICARE COVERAGE ONLY