Incident/accident Questionnaire Template - Department Of Vermont Health Access
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1
2DVHA 248
R 11/2011
Insurance/Accident Questionnaire
____________________________________________________________________________________________________________________________________________________________________________________
Department of Vermont Health Access (DVHA)
Accident Questionnaire Team
Phone: 802-879-4450 Press Option 5
ATTN: Accident Response
OR 1-800-925-1706 Press Option 5
Hewlett Packard Enterprise
Fax: 802-857-2992
PO Box 1645
Williston, VT 05495-9983
____________________________________________________________________________________________________________________________________________________________________________________
As a Medicaid or VHAP beneficiary, medical care has been paid for you or your dependent(s), resulting from an accident,
injury, illness or condition. There may be other insurance (health, auto, injury insurance) or some other source which
could pay for this care. Please fill in the boxes, answer all four questions, sign, and return this questionnaire to us within
ten (10) days in the enclosed stamped / addressed envelope.
If you have questions, please call us directly at 1-800-925-1706, Option 5.
Failure to complete and return the questionnaire may result in closure of your Medicaid/VHAP coverage or denial
of a future Medicaid/VHAP application.
Patient's Name
Date of Birth: _________________
:
____________________________________________
(Please Print)
Medicaid I.D.#
Soc.Sec.#
Date of Incident:
: ____________________
: ___________________
__________________
Case #
Check only one that applies
accident
injury
illness or condition
: _________________
:
(from cover letter)
Explain what happened and list all injuries
: ________________________________________________________________
___________________________________________________________________________________________________________
QUESTION 1 - Was the patient covered by any insurance such as cancer, accident, disability, indemnity, group or
individual health insurance other than Medicaid, VHAP, or Medicare on the date of the accident, injury,
illness or condition?
NO
YES (If yes, complete the following)
Name and address of insurance company (ies): ______________________________________________________________________
____________________________________________________________________________________________________________
Policy number(s): ______________________________ Policy holder(s): _______________________________________________
QUESTION 2 - Was medical care related to an automobile accident that caused injury?
NO
YES
(If YES, complete the following)
Patient was the:
driver
passenger
pedestrian
Vehicle was a:
auto
motorcycle
bus
other – please specify: _____________________________
N/A
Were you at fault?
as another person at fault?
NO
YES
W
NO
YES
“Your”
her Person’s”
Name & Address:
insurance company:
Name & Address: “Ot
insurance company:
_________________________________________________
__________________________________________________
_________________________________________________
__________________________________________________
Policy #: _________________________________________
Policy #: __________________________________________
Policy Holder: ____________________________________
Policy Holder: ______________________________________
Name and address of all vehicle drivers: ___________________________________________________________________________
____________________________________________________________________________________________________________
Name of Police Department that investigated: ______________________________________________________________________
(Turn over, please.)
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