Get Eiia Claim Form

Filling out the EIIA Claim Form online is a straightforward process designed to expedite your claims submission. This guide will provide you with step-by-step instructions on how to effectively complete each section of the form to ensure it is processed smoothly.

Follow the steps to accurately complete your EIIA Claim Form online.

1. Press the ‘Get Form’ button to access the EIIA Claim Form.
2. Begin with Part 1, the student statement. Enter the school name, policy number, and personal information including the student's last name, first name, and ID number. Be sure to provide a complete street address.
3. Continue to fill in the phone number, email address, date of birth, and select your gender. Specify your relationship status and indicate the type of claim you are submitting, whether it is due to an accident or sickness.
4. If applicable, detail any sport involvement by checking the appropriate box and specifying the type of sport. Record the exact date of the incident and the first date of medical treatment. Include the provider’s name and phone number.
5. If your condition is related to a sickness, explain the reason for seeking medical treatment and indicate whether you have had issues with this condition in the past.
6. For any previous related treatments, provide the last treatment date and the name and contact information of your prior treating physician.
7. If you were referred by Student Health Services, mark 'yes' and provide the required signature from the official.
8. Proceed to Part 2 for the parent or guardian statement. Fill in their details, including date of birth, insurance information, and confirm if the student is insured. If there is any other coverage, ensure that you have the necessary explanation of benefits (EOBs).
9. Next, complete Part 3, which must be filled out by an athletic department official. Ensure that all details regarding the athletic status and incident are correctly filled out.
10. Upon completing all sections of the form, review it for accuracy. Save the changes, download, and print a copy for your records. Ensure that you submit the form as directed, along with any required attachments.

Complete your EIIA Claim Form online today for timely processing of your claim.