Member/Patient Information

Member/Patient Information
Member Name:
Patient Name:
Name of Health Plan:
Member Number or Group Number:
Accident/Incident Information
Brief description of accident/incident (e.g., motor vehicle accident, job-related injury, illness, etc.):
Date, time, and location of accident/incident:
Has a workers’ compensation claim been filed, or will one be filed for this injury?

Additional Information/Comments
Please provide additional comments/description of circumstances and cause(s) of your accident or incident:
*****REQUIRED*****
I hereby acknowledge and agree to the terms of my plan’s subrogation, reimbursement and/or third party recovery provision(s). I authorize the release of medical information relating to this incident to, and by, my plan administrator, claims administrator, and McAfee & Taft.
First Name:
Last Name:
Home or Cell Phone:
Work Phone:
Date Signed

MonthDayYear
***By typing my name in the designated spot above, I convey my intent to submit this information as part of an electronic transaction. My name as it appears in the designated spot constitutes my electronic signature, and I intend it to be binding in all related matters. Any dispute related to this electronic signature or its validity shall be governed by the laws of the state of Oklahoma.***
Should be Empty: