Form Ms-08-453 - Accidental Injury Form - United Healthcare
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1Accidental Injury Form
Please complete and mail this form with all supporting documentation to:
Oxford Coordination of Benefits Department, P.O. Box 29143, Hot Springs, AR 71903 • 1-800-767-3840
Oxford ID number: ___________________________
Was your medical treatment the result of an: Automobile accident:
Yes _____ No _____ If yes, complete Section A
Work related accident:
Yes _____ No _____ If yes, complete Section B
Other:
Yes _____ No _____ If yes, complete Section C
A. Automobile Accident
Date of accident _____________________________ Injuries sustained _______________________________________________
Were there any other family members involved who are enrolled with Oxford?
Yes____ No_____ If yes, member’s name:
• Name ___________________________________ Injuries sustained ________________________________________________
• Name ___________________________________ Injuries sustained ________________________________________________
Was this a motorcycle accident?
Yes _____ No _____
Has a motor vehicle claim been filed with your automobile carrier?
Yes _____ No _____
Auto carrier information, if more than one carrier is responsible include that information:
Auto carrier name & address _________________________________________________________________________________
Auto carrier phone # ______________________________ Policy # _________________________ Claim # _________________
Other auto carrier name & address ____________________________________________________________________________
Auto carrier phone # _______________________________ Policy # ________________________ Claim # _________________
Have you filed a report of the injury? Yes _______ No _______ If no, why? __________________________________________
If you live in New Jersey, who have you opted to pay primary for medical claims? Check one:
Health insurance carrier _______
Auto carrier _______
If you live in Connecticut, do you have Med Pay on your automobile policy?
Yes _____ No _____
B. Work-Related Accident
Date of accident ___________________________ Injuries sustained _________________________________________________
Have you filed a report of the injury?
Yes ______ No ______ If no, why?___________________________________________
If yes, name and address of workers’ compensation carrier _________________________________________________________
_______________________________________________ Policy # _______________________Case #______________________
C. Attorney Information
Have you hired an attorney?
Yes _____ No _____
If yes, attorney’s name__________________________________________
Address ____________________________ _________________________________Phone # _____________________________
D. Complete this section if your injury occurred on property other than your own
Name and address of property owner __________________________________________________________________________
_________________________________________________________________________________________________________
Property owner’s insurance carrier _____________________________________________________________________________
Phone #___________________________________ Claim #________________________________________________________
Do you intend to make a claim with the property owner’s insurance carrier?
Yes _____ No _____
E. Applicant Signature
I certify that the above information is true and accurate to the best of my knowledge.
Print name _______________________________ Signature _______________________________ Date _________________
Authorization to release medical records relating to this accident or injury
Print name _______________________________ Signature _______________________________ Date _________________
MS-08-453 Rev 1 02/2013
4217 R7
UHCEW631250-000
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Parent category: Medical