Get Relinquishment Form - Group Health Cooperative Of Eau Claire

This guide provides detailed instructions on completing the Relinquishment Form for the Group Health Cooperative of Eau Claire online. This process is straightforward and requires careful attention to each field to ensure compliance with all requirements.

Follow the steps to accurately complete the Relinquishment Form.

1. Click the ‘Get Form’ button to download the Relinquishment Form. Open the form in your preferred document editing software.
2. Fill in the 'Facility Name' field with the name of the medical facility submitting the request for relinquishment.
3. Provide the 'Date of Service(s)/Amount of Claim(s)' by entering the specific dates services were rendered and the corresponding claim amounts.
4. Indicate the 'Type of Accident' by describing the nature of the incident that led to the service.
5. Enter the 'Patient Name' field with the name of the individual who received the medical treatment.
6. Input the 'Member/MA#' which is the Medicaid identification number associated with the patient.
7. Provide the 'Reason for Request', detailing why this form is being submitted for relinquishment.
8. Sign the form in the designated 'Signature' section to confirm your agreement to relinquish subrogation rights.
9. Date the form in the specified 'Date' section next to your signature.
10. Fill out your 'Title' and 'Phone' number for identification and communication purposes.
11. If applicable, provide information regarding any third-party liability coverage or attorney representation, including the 'Name of Insurance Company or Attorney,' their 'Address,' and 'Phone'.
12. After verifying all information for accuracy, save your changes. You may then print, download, or share the form as needed.

Complete your Relinquishment Form online today to ensure prompt processing and compliance.