Get This Notification Of Injury Form Is To Be Used For Accident Medical Claims

This guide provides step-by-step instructions on how to accurately fill out the Notification of Injury Form for accident medical claims online. By following these instructions, users can ensure a smooth submission process, ultimately expediting their claim handling.

Follow the steps to successfully complete your claim form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Complete Part (A) of the claim form, ensuring you include the name of the organization, policy number, address, and details about the injured person, including their name and the date of the accident.
3. In Part (A), indicate whether the injured person was engaged in an activity under the jurisdiction of the organization at the time of the accident and provide an explanation of how the injury occurred.
4. Fill out Part (B) of the claim form. This section must be completed and signed by the injured person or their parent or guardian if the injured person is under 18.
5. Provide the injured person’s date of birth, contact information, and details about any other health insurance coverage they may have.
6. Attach all itemized medical bills to the claim form. Ensure these bills are compliant with the required formats, such as CMS 1500 or UB04.
7. Verify that all necessary sections of both parts of the form are completed and signed appropriately.
8. Once all information is filled out and attached, save your changes, download, print, or share the form as needed for submission.

Complete your Notification of Injury Form online today for a seamless claims process.