Get Premera Incident Questionnaire

Completing the Premera Incident Questionnaire online is a crucial step in processing your claims effectively. This guide offers a clear and structured approach to filling out the form to ensure that all necessary information is accurately provided.

Follow the steps to complete the Premera Incident Questionnaire online.

1. Use the ‘Get Form’ button to access the Premera Incident Questionnaire and display it in the editor.
2. Begin with filling out the section labeled 'Today’s Date,' providing the current date.
3. Next, enter the patient’s name followed by the member’s name and address details.
4. Fill in the patient’s date of birth along with the member ID number and group number.
5. Specify the provider and the service date(s) related to the incident.
6. In the 'Cause of Injury or Condition' section, select the type of incident that applies to your situation and provide a description where necessary.
7. Address the required information concerning the date and type of injury or condition sustained.
8. If the incident occurred on a property, indicate whether you own the property and provide location details as asked.
9. Answer all follow-up questions regarding property type, location owner representative name, and insurance details, if necessary.
10. If applicable, address the work-related questions, including Workers’ Compensation Insurance coverage.
11. Continue to fill in the mandatory details regarding any motor vehicle involvement if it applies to your incident.
12. Review all the information filled, ensuring that nothing is left blank or marked as ‘N/A’ where it applies.
13. After completing the form, save any changes, and choose to download, print, or share the form as needed.

Complete your Premera Incident Questionnaire online today to expedite your claim process.