Incident/accident Questionnaire Template - Department Of Vermont Health Access Page 2
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1
2QUESTION 3 - Was medical care related to anything other than a motor vehicle accident?
NO
YES
(If YES, answer questions 3A-3C)
3A) Was this related to a Worker’s Comp (injury on the job) claim?
NO
YES (If yes, complete the following)
Employer’s name: ___________________________________
Worker’s Comp Company:
______________________________
Address: ___________________________________________
______________________________________________________
__________________________________________________
Case or Account #:_______________________________________
Telephone Number: __________________________________
Telephone Number:______________________________________
If patient’s injury or accident was caused by another person or occurred on someone else’s property (store,
3B)
school, neighbor’s home, relative’s home, business, etc.), did they have insurance (car, homeowner’s or other
liability insurance)?
(If yes, complete the following)
NO
YES
Name and address where injury occurred: __________________________________________________________________________
____________________________________________________________________________________________________________
Name and address of insurance company: __________________________________________________________________________
_______________________________________________________________ Case Number: _______________________________
Was this an assault?
3C)
NO
YES (If yes, please describe) _______________________________________________
____________________________________________________________________________________________________________
QUESTION 4 - Has an attorney been retained as a result of this accident/injury/illness/condition?
NO
YES
(If yes, complete the following)
Attorney’s name, address, and phone number: _______________________________________________________________________
____________________________________________________________________________________________________________
Was there a settlement
?
NO
YES (If Yes) Amount: $_______________________ Date: _______________________
When Medicaid has paid or will pay for any medical care required as a result of an accident/injury/illness/condition caused by another
person or party, or if the payment for this medical care is another's legal responsibility, the DVHA can assert the rights and claims of
the Medicaid beneficiary against the responsible person or party, to the extent of the medical payments made by, or to be made by the
DVHA. In other words, the state has the right to collect any money from a third party involved in the personal injury or related
illness/condition in order to be reimbursed for the cost of your care.
You must cooperate with the DVHA to secure and protect these rights and claims. You shall not settle or compromise these rights
or claims without prior written consent from the DVHA. You also agree that the DVHA may take legal action to protect or
recover these claims.
______________________________________________________________
___________________________________
Signature of Beneficiary, Parent - if beneficiary is a minor, or Legal Guardian
Date
_____________________________________________________________
___________________________________
If signed by parent or legal guardian, please print your name
Daytime telephone number
Additional Comments (Attach additional sheets if necessary): _________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
(You should submit any additional information, if and when it becomes known.)
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