I, the employee, verify the statements made above are true and accurate to the best of my knowledge. I acknowledge that federal laws provide for criminal penalties for submitting knowingly or making false, fictitious or fraudulent statements or claims in any manner. This information is requested to update enrollment records and used to determine eligibility for benefits and to review and process claims. 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 The Phia Group, and is subject to HIPAA, as amended.
