Fillable Usa Volleyball Medical Claim Form printable pdf download

SEND THIS FORM TO:

American Specialty Insurance & Risk Services, Inc.

USA VOLLEYBALL

7609 W. Jefferson Blvd.

Suite 150

MEDICAL CLAIM FORM

Ft. Wayne, IN 46804

2015-2016 Season

Customer Service Number: 800-245-2744

Email:

This form should be completed whenever a medical claim results from an injury incurred at USA Volleyball sanctioned events.

PLEASE ANSWER ALL QUESTIONS. INDICATE “N/A” IF INFORMATION IS NOT APPLICABLE.

TO BE COMPLETED BY INJURED PARTY

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NAME

(Last Name)

(First Name)

(Middle Initial)

SOCIAL SECURITY NUMBER

DATE OF BIRTH

SEX

ADDRESS

(Street)

(City)

(State)

(Zip Code)

TELEPHONE NUMBER

OCCUPATION

(

)

USA VOLLEYBALL PARTICIPANT #:

DATE & TIME OF ACCIDENT:

______/______/______

_________ ___ AM ___ PM

INJURED PARTY WAS:

PARTICIPANT

COACH

OFFICIAL

VOLUNTEER

OTHER: ____________________________

IF PARTICIPANT, MEMBERSHIP TYPE:

JUNIOR MEMBER

ADULT MEMBER

NATIONAL OR HIGH PERFORMANCE TEAM MEMBER

REGIONAL ASSOCIATION NAME:

COACHES NAME:

PHONE #:

(

)

NATURE OF INJURY

FOR ALL INJURIES, PLEASE COMPLETE THE FOLLOWING:

A. DESCRIBE ACTIVITY ENGAGED IN AT TIME OF ACCIDENT:

______________________________________________________________________________________________________________________________

B. DESCRIBE WHERE ACCIDENT HAPPENED:

______________________________________________________________________________________________________________________________

C. DESCRIBE HOW ACCIDENT HAPPENED:

______________________________________________________________________________________________________________________________

D. DID THE ACCIDENT OCCUR DURING:

COMPETITION

PRACTICE

TRAVELING TO/FROM

OTHER: ______________________________________________

E. WITNESS NAME: _______________________________________________________

PHONE #: ____________________________________

IF INJURED PARTY IS A MINOR:

PARENT/GUARDIAN NAME: ______________________________________________

HOME PHONE #:______________________________

EMPLOYER NAME: ______________________________________________________

WORK PHONE #:______________________________

IS THE INJURED PERSON COVERED UNDER ANY OTHER HEALTH AND/OR ACCIDENT INSURANCE PLANS, INCLUDING BUT NOT LIMITED TO GROUP

OR INDIVIDUAL MEDICAL, MILITARY/GOVERNMENT PLANS SUCH AS MEDICARE, OR AUTOMOBILE PLAN?

YES

IF YES, NAME OF INSURANCE COMPANY

POLICY NUMBER

ADDRESS

(Street)

(City)

(State)

(Zip Code)

AUTHORIZATION TO RELEASE INFORMATION

I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release my information regarding medical, dental, mental, alcohol

or drug abuse history treatment or benefits payable, including disability or employment related information, to American Specialty, the Plan Administrator, or their

employees and authorized agents for the purpose of validating and determining benefits payable.

I understand that my authorized representative or I will receive

a copy of this authorization upon request. This authorization or a photo static copy of the original shall be valid for the duration of the claim.

NAME OF PATIENT

SIGNATURE OF PATIENT (PARENT/GUARDIAN IF A MINOR)

DATE

SIGNATURE

DATE

I certify that the foregoing information is true and correct.

The completion of this form is not an admission of the existence of any insurance nor does it recognize the validity of any claim

and is without prejudice to the Company’s legal rights in the premises.

2015-2016 Season Insurance Handbook