Acciden Veri˜ca Form - chministries.org

1 Return to: Christian Healthcare Ministries Attn: Member Bill Processing map-marker-alt 127 Hazelwood Ave. Barberton, OH 44203 33 0 . 8 4 8 .1511 toll free Verification FormINSTRUCTIONS: Please complete the following form so that CHM may process your medical bills in accordance with the CHM INFORMATIONP atient name: Member #: GENERAL INFORMATIONDate of injury : / / Check the box that most accurately represents the event type resulting in your medical treatment:square Motor vehicle accident square Injured at home square Injured on someone else s propertysquare Injured at work square Injured at school square OtherBriefly describe what led to the medical treatment.

2 MOTOR VEHICLE ACCIDENT (AUTO, MOTORCYCLE, BOAT, ETC)Was the patient the: square Driver square Passenger square PedestrianList if the injury /accident occurred on private or public property: Name and address of the liable party: Insurance company: Claim/policy #: Address: Phone #: Adjuster s name: Phone #: List the first and last names of additional CHM members involved in the accident: For motorcycle or ATV accidents, were you wearing a helmet? square YES square NOFor motor vehicle or ATV accidents, were you wearing a seatbelt? square YES square NOIn order for your medical need to be reviewed and/or shared, CHM must receive the following (when applicable).

3 Copy of the police or accident report Verification of your medical payment coverage terms (in some states this is called personal injury protection or PIP) and limits from your automobile insurance carrier (available through your insurance agent) Copies of signed third party responses, including insurance companies, regarding the acceptance of denial of liability Evidence of the total amount paid by your auto insuranceWORK RELATED ( injury /ACCIDENT IN THE SCOPE OF EMPLOYMENT)Employer name (or write self-employed ): Phone #: Worker s compensation carrier: Claim/policy #: Adjuster s name: Phone #: IF injury OCCURRED ON SOMEONE ELSE S PROPERTY (SLIP AND FALL, DOG BITE, ETC.)

4 Name and address of the liable party or property owner: Insurance company: Claim/policy #: Address: Phone #: Adjuster s name: Phone #: Please include a signed copy of the third party responses regarding the acceptance or denial of INFORMATION Are you pursuing a personal injury claim? square YES square NO Attorney s name: Law firm name: Phone #: Has the injury claim been settled? square YES square NO If so, on what date was the settlement finalized: / / Please include a signed copy of the ASSISTANCE (INCLUDING VICTIM ASSISTANCE)Name and addresses of financial assistance institutions to which you have applied:1.

5 2. By signing below, I attest that the information provided on this form is true to the best of my knowledge. Name (please print): Member #: Signed: Date: / /