Bcbsm Subrogation PDF Details

When navigating the aftermath of an incident that involves potential legal action or insurance claims, one document from Blue Cross Blue Shield of Michigan (BCBSM) becomes particularly relevant: the BCBSM Subrogation Unit Questionnaire. This form, utilized by the Subrogation Department located in Lansing, Michigan, serves a crucial role in the cases where BCBSM seeks reimbursement for medical expenses from a third party responsible for a member's injuries. These scenarios can range from personal injury and workers' compensation to product liability and motor vehicle accidents. The detailed questionnaire requests comprehensive information including the client's identification, the type of case, details of the incident like date and nature of the injury, and jurisdictional information. It necessitates the involvement of the insured's attorney and insurance adjusters, providing their contact details along with the specifics of the legal action, such as hearing dates. By filling this form, policyholders or their representatives initiate the process where BCBSM assesses the possibility of recovering costs it incurred for the member’s treatment, thus intertwining legal proceedings with insurance interests. This integration underlines the importance of the BCBSM Subrogation Unit Questionnaire in ensuring that funds are appropriately allocated following an event where another party is deemed liable for a member's injuries.

QuestionAnswer
Form NameBcbsm Subrogation
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessubrogation bcbsm com, bcbsm unit, anthem com subrogation, subrogation

Form Preview Example

Office of the General Counsel Subrogation Department

232 S. Capitol Ave., L09A Lansing, Michigan 48933-1504 (517) 325-4658

FAX No. (877) 257-2012

E-mail: SubrogationUnit@bcbsm.com

BCBSM SUBROGATION UNIT QUESTIONNAIRE

FAX COMPLETED FORM TO 877-257-2012

Date

Client’s Name

 

Date of Birth

 

 

 

 

Contract # (9 digit number on BCBSM card)

Spouse (if on BCBSM policy)

 

 

 

BCBSM policy holder’s name (if different from the client’s name)

 

Date of Birth

 

 

 

 

Client’s phone number

 

 

 

Type of case (select one) Personal Injury

Product liability

Medical malpractice

Workers’ compensation

(Please fax the application if in Michigan)

 

Motor vehicle accident

In what state did it occur?

 

 

 

 

 

In what state does the liable party live?

 

Motorcycle accident

Was a vehicle involved? Yes

 

 

 

No

 

 

 

 

 

 

 

 

Other

Venue/Jurisdiction of cause of action

Date of injuryType of injury/area of body injured

NOTES:

Attorney name

Attorney law firm name

Attorney street address

City

 

State

Zip code

 

 

 

 

 

Attorney phone number

 

Attorney fax number

 

 

 

 

 

 

 

 

 

 

 

Insurance company name

 

 

 

 

 

 

 

 

 

Insurance adjuster name

 

Insurance claim number

 

 

 

 

 

 

Insurance company street address

City

 

State

Zip code

 

 

 

 

 

Insurance adjuster phone number

 

Insurance adjuster fax number

 

 

 

 

 

 

Date and type of next scheduled hearing date

 

 

 

 

 

 

 

 

 

FAX COMPLETED FORM TO 877-257-2012

Blue Cross Blue Shield is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

WF 10345 AUG 11

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