Accident Claim Form

Accident Claim Form
Regional Care Inc., the claims administrator for your benefit plan, has received a medical claim that requires additional information to process. The purpose of this online form is to ensure that no other party is responsible for payment of this claim. In accordance with the terms of the plan document, your cooperation is required in providing the requested information. Please submit this information within 10 days of receiving the notification letter. You can also fax the information to (308) 635-2018 or mail the information to:

Regional Care Inc.905 W. 27th Street, Scottsbluff, NE 69361.

Please attach any supporting documentation at the bottom of this form.

Fields with * are Required
Employee Name:*

First NameLast Name
Patient Relationship:*

EmployeeDependant
Patient Name:*

First NameLast Name
Patient ID#:*
Treatment Date:*

MonthDayYear
Treatment For:
General Information
IF THE TREATMENT WAS DUE TO ONE OF THE FOLLOWING, MARK ONE:*

Motor Vehicle AccidentWork accident (worker's compensation, etc.)Slip/Fall/Injury (Not Your Home)Slip/Fall/Injury (Your Home)Sport Related Injury (School / Claim was filed with other insurance company)Sport related injury (Recreational/No other insurance coverage)Other party responsible (malpractice, animal bite, etc.)Ongoing condition (chronic back pain, arthritis, etc.)Other
If other... describe below:*
If other party is responsible... specify the responsible party:
If work accident that was workers compensation filed?*

YesNo
Signature:*
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail

Please describe the incident below:
Date:*

MonthDayYear
Type of incident*
Type of injuries sustained*
Do you have an attorney assisting you with this incident?*

YesNo
Are you still being treated?*

YesNo
Did you file a claim (other than with RCI)?*

YesNo
If yes, with whom?*
Incident details please type location below:*
Location Description:*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Motor Vehicle Accident Information
If it was a motor vehicle accident please fill out the following...
MVA Type *

Single VehicleMultiple Vehicle
Names of other people injured in accident:
Police report filed? (Please scan and attach a copy of the police report):*

YesNo
Who was at fault?*
Who, if anyone, was cited?:*
Did you receive a settlement?:*
Your Automobile Insurance Information:
Driver Name:*

First NameLast Name
Owner Name :*

First NameLast Name
Owner Address*

Street Address

Street Address Line 2

CityState

Zip Code
Owner Phone:

Area CodePhone Number
Insurance Company:
Adjuster Name:
Adjuster Phone:

Area CodePhone Number
Insurance Address:

Street Address

Street Address Line 2

CityState

Zip Code
Claim Number:
Policy Number:
Responsible Party's Automobile Information:
Full Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:

Area CodePhone Number
Insurance Company:
Adjuster Name:
Adjuster Phone:

Area CodePhone Number
Insurance Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Claim Number:
Policy Number:
Workers Compensation Claim Information
If it was a work related accident please fill out the following...
Did you notify your employer of your injury/accident?:*

YesNo
Did you file a workers' compensation (WC) Claim?:*

YesNo
If yes, was your claim approved?:

YesNo
If no, are you still pursuing a claim with the WC carrier?:*

YesNo
Employer Name:*
Employer Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:

Area CodePhone Number
WC Insurance Company:
Adjuster Name:
Adjuster Phone:

Area CodePhone Number
WC Insurance Address:

Street Address

Street Address Line 2

CityState

Zip Code
Claim Number:
Policy Number:
Other Insurance Claim Information
If it was Homeowners, Medical Malpractice, Slip and Fall or Other Insurance Claim please fill out the following...
Name of Responsible Party (RP):*
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:

Area CodePhone Number
RP Insurnace Company:
Adjuster Name:
Adjuster Phone:

Area CodePhone Number
Insurance Address:

Street Address

Street Address Line 2

CityState

Zip Code
Claim Number:
Policy Number:
Attorney Information
If you have a lawyer please fill out the following...
Attorney Full Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
Fax Number:

Area CodePhone Number
E-mail:
Please Sign and Date Below

I hereby acknowledge and agree to the terms of my Plan's Third Party Recovery provision, which provides that the Plan has subrogation and/or reimbursement rights to the medical claims paid on my behalf. I acknowledge that I have an obligation to cooperate with the Plan and provide the Plan with information pertinent to protection these Plan rights. I authorize Regional Care, Inc. and The Phia Group to release information regarding any claims in accordance with the Plan's subrogation and/or reimbursement rights. Furthermore, I hereby authorize any medical provider, my lawyer or agent, or any other person or corporation to release any and all medical information relating to this incident to The Phia Group.

Signature of Plan Member:*
Signature Date*

MonthDayYear
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
E-mail:
Select Files
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File 4

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If mailing this form, send the completed form to:
Regional Care, Inc., 905 West 27th Street, Scottsbluff, NE 69361
Fax - (308) 635-2018
For Customer Service, Please Call: (308) 635-2260 or (800)-795-7772

Should be Empty:

Accident Claim Form

Please describe the incident below:

If it was a motor vehicle accident please fill out the following...

Your Automobile Insurance Information:

Responsible Party's Automobile Information:

If it was a work related accident please fill out the following...

If it was Homeowners, Medical Malpractice, Slip and Fall or Other Insurance Claim please fill out the following...

If you have a lawyer please fill out the following...