Get Ics Medical Accident Questionnaire

Filling out the ICS Medical Accident Questionnaire is a vital step following an accidental injury. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete the form online

1. Press the ‘Get Form’ button to obtain the questionnaire and open it for editing.
2. In section A, patient information, enter your name (last, first, middle initial), alias if applicable, date of birth in MM/DD/YY format, policy ID number, policyholder name, date of the accident in MM/DD/YY format, and provide a detailed description of how the accident occurred. If more space is needed, you can use the back of the form.
3. Indicate whether any other person was responsible for causing your accident by selecting 'Yes' or 'No.' If 'Yes,' provide an explanation.
4. Answer whether you were under the influence of drugs or alcohol at the time of the accident by selecting 'Yes' or 'No.'
5. Confirm if there is another insurance plan that may have a financial obligation related to this injury (e.g., Workman’s Compensation, Automobile, Property insurance) by selecting 'Yes' or 'No.' If 'Yes,' include the details of the other plan’s policyholder, policy number, plan name, and contact number.
6. Attach a copy of the official police accident report if it is applicable, as this may be needed for the claims process.
7. In section B, primary treating physician information, input the physician's name, address, and telephone number.
8. Review the fraud warning in section C, which emphasizes that submitting false information can lead to insurance fraud.
9. Finally, ensure all sections are accurately filled. You can then save your changes, download, print, or share the completed form as required.

Start completing your ICS Medical Accident Questionnaire online today!