Get Nd Sfn 566 2015-2025

The ND SFN 566 form is essential for individuals seeking to report information regarding Medicaid services and potential recoveries from accidents or injuries. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the ND SFN 566 online.

1. Press the ‘Get Form’ button to obtain the ND SFN 566 form and open it in your editing tool.
2. In Section I, provide your full name, telephone number, mailing address including street, city, state, and ZIP code. Additionally, enter your Medicaid case number and Medicaid ID number. If applicable, check 'Yes' or 'No' regarding other family members injured, and fill in details about the accident, such as date, time, and location.
3. Continue in Section I by indicating if you are receiving insurance or other benefits related to the accident. If yes, provide the contact person's name and address. Also, state if you have considered legal action and provide your attorney's name and contact details if applicable.
4. Move to Section II if your accident was vehicle-related. Specify if you were a driver, passenger, or pedestrian and fill in the insurance details, such as policyholder name, insurance company, policy number, and claims information.
5. If your accident involved another vehicle, collect necessary details about the other driver and their insurance coverage. Confirm if you or a family member owns a vehicle, and provide insurance details if applicable.
6. For other types of accidents, complete Section III with the location and relevant insurance details, followed by Section IV concerning Workers Compensation. Fill in your employer's information, type of injury, and outline whether you have filed a Workers Compensation claim.
7. Finally, read and complete the Medicaid Assignment of Benefits section. Print your name, sign the form, and include the date. Ensure that all sections are filled out as required before submission.
8. Once you have filled out the form completely, save your changes, and you may download, print, or share the form as needed.

Start filling out your ND SFN 566 form online today for a seamless submission process.