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eSubrogation Questionnaire

If you have any questions or need assistance please call us at 1-866-891-7397,
Monday – Friday 9:00 AM to 4:00 PM ET.
Si desea obtener instrucciones acerca de cómo completar este formulario en español, por favor llame al 1-866-891-7397

Note: Required Field

Please enter the following information from our Subrogation Questionnaire
Policy Holder Name: (first,mi,last)
Patient Name: (first,mi,last)
Date of Service:       (mm/dd/yyyy)
Case Number:
Claim Number:
Email:
At least one phone number
must be supplied.
Day Phone: ( )  -   - 
Evening Phone: ( )  -   - 


If you are unsure whether the care was due to an accidental injury where another person, employer or insurance company may be responsible for payment of the medical services, please call us at 1-866-891-7397, Monday – Friday 9:00 AM to 4:00 PM ET.



Was the care provided for the services noted on the Subrogation Questionnaire a result of a WORK RELATED injury or illness?
 Yes   No

Was the care provided for the services noted on the Subrogation Questionnaire due to accidental injury where ANOTHER person or insurance company may be responsible for the payment of the medical services?

 Yes   No
Was the care provided for the services noted on the Subrogation Questionnaire due to an accidental injury that was YOUR fault?
 Yes   No

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