Follow the steps to complete the questionnaire successfully.

1. Click ‘Get Form’ button to access the Third-Party Liability Questionnaire Form and open it in your online editor.
2. Fill in your personal information at the top of the form, including the date, name of the insured or subscriber, name of the patient, member ID number, and date(s) of service.
3. Provide a detailed description of the injury or illness by answering the questions in the General Information section. Be sure to include the date, location, and circumstances of the incident.
4. Indicate whether you have hired an attorney or retained legal counsel. If applicable, provide the attorney's name and address.
5. Answer whether a police report was made regarding the incident. If yes, be sure to attach a copy of the report.
6. If the injury is work-related, fill out the specific section by providing your employer's name and phone number, and indicate if you filed for Workers' Compensation.
7. For motor vehicle-related incidents, indicate that information, listing your involvement in the accident, and provide the necessary insurance details.
8. If others may be responsible for your injury or illness, answer the questions in this section, including their contact details and the status of any claims made against them.
9. Review and agree to the Reimbursement Agreement section, ensuring you understand your obligations regarding HMAA's reimbursement rights.
10. After completing all sections, make sure to sign and date the form. If someone other than the patient is signing, indicate their relationship to the patient.
11. Finally, save your changes, and you can download, print, or share the completed form as needed.

Complete your Third-Party Liability Questionnaire Form online today.