CurrentFlorida BluePolicy N/A

Accident/Third-Party Liability Questionnaire

Forms and instructions for insured members to report accidents, potential third-party liability, automobile-related incidents, and work-related injuries to Florida Blue/Health Options to support claim coordination and subrogation. Affects insured members submitting claims related to accidents or potential liable third parties.

Policy Summary

PayerFlorida Blue

PolicyAccident/Third-Party Liability Questionnaire

Policy CodePolicy N/A

Change TypeAdministrative — form/instruction update (no material coverage change)

Effective DateN/A

Next Review DateN/A

Key ActionComplete, sign, and return the questionnaire within 30 days and provide required documentation (accident report, insurer details, workers' compensation decision) as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

P.O. Box 45287mailing address

1-904-997-5224fax

30 daysreturn timeframe

Yessignature required

Member Requirements for Accident / Third-Party Cases

Required member responses and documentation for claim coordination and subrogation

Information requested and required actions by the member when an accident or potential third-party liability is involved:

Member must respond to initial screening question about whether the claim is related to on‑the‑job injury/illness, an automobile accident, or if another party may have liability; return completed questionnaire within 30 days.

If No: Provide a brief description of the claim and complete Section A.

If Yes: Complete Section A and the appropriate Section(s) B–D that pertain to the injury/illness or accident.

Section A: Member attestation and contact information: sign and date the form to attest information is true, and provide home and work phone numbers. Signature authorizes any Medicare carrier, intermediary, insurance carrier, or plan to make available to Florida Blue/HOI all records necessary for processing claims filed by the member or on the member's behalf.

Policy Summary

PayerFlorida Blue

PolicyAccident/Third-Party Liability Questionnaire

Policy CodePolicy N/A

Change TypeAdministrative — form/instruction update (no material coverage change)

Effective DateN/A

Next Review DateN/A

Key ActionComplete, sign, and return the questionnaire within 30 days and provide required documentation (accident report, insurer details, workers' compensation decision) as applicable.

SourceLink

On This Page

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Section B – Automobile-related information

Provide date and location of the accident.
Indicate whether a claim has been made to your auto insurance carrier; if yes, provide auto insurer name, mailing address, phone, policy number, and claim number.
Indicate whether you have a No‑Fault deductible; if yes, provide a copy of your automobile coverage limits.
Indicate whether you were a guest passenger in another vehicle.

Section B – Work‑related information

Provide initial date and cause of the injury/illness.
Indicate whether a workers' compensation claim has been filed by your employer; if yes, state whether the case was accepted or denied and provide documentation supporting the decision plus case/claim number, carrier name, mailing address, and phone number.
If a workers' compensation claim was not filed, explain why and provide any available documents.
If self‑employed, provide the name of your workers' compensation carrier.

Section D – Potential third‑party liability

Provide date and type of accident or injury/illness (e.g., automobile, slip and fall, malpractice or describe other).
Provide insurance information for the individual who caused the accident/illness: insurer name, mailing address, responsible party name, policy number.
Indicate whether you have sought the assistance of an attorney; if yes, provide attorney name, mailing address, and phone number.

Provide supporting documentation as applicable (copy of accident report, automobile coverage limits, and workers' compensation decision documentation) to support coordination and subrogation efforts.

Return the completed form by mail or fax within 30 days to ensure accurate processing of future claims (mailing address and fax number provided on the form).

Billing and Code References

No billing or coding references in formmixed

Form submission and timing

Return addressP.O. Box 45287, Jacksonville, FL 32232-9805

Fax for completed form1-904-997-5224

Recommended timeframe to return questionnaireComplete, sign, and return within 30 days

Member Authorization and Release Actions

Documentation Required

Member authorization for records disclosure

Signature on Section A authorizes any Medicare carrier, intermediary, insurance carrier, or plan to make available to Florida Blue/Health Options, Inc. (HOI) all records necessary for processing claims filed by the member or on the member's behalf.

Member must sign Section A to provide this authorization.
Authorization covers records disclosure to Florida Blue/HOI for claim processing purposes.

Form Sections and Contact Details

Section A — Attestation, signature, and contact

Member attestationTo the best of my knowledge the information is true, accurate, and complete; unanswered questions indicate they do not apply

Authorization for records disclosureSignature authorizes any Medicare carrier, intermediary, insurance carrier, or plan to make available to Florida Blue/HOI all records necessary for processing claims filed by me or on my behalf

Member contact details requiredMember name, address, phone number, contract number and date of service/date of accident

Section B — Auto- and work-related incident information

Automobile incident detailsDate and location of accident; provide a copy of the accident report

Auto insurance informationName of auto insurance, mailing address, phone number, policy number, claim number

No-Fault deductible and limitsIndicate if you have a No-Fault deductible and provide copy of automobile coverage limits if Yes

Work-related injury detailsInitial date and cause of injury/illness; indicate if workers' compensation claim filed and provide case/claim number, carrier name, address, phone and documentation of acceptance/denial

Section D — Potential third‑party responsible party details

Responsible party insuranceProvide insurance company name, mailing address, responsible party name and policy number

Accident/injury details for third partyDate and type of accident or injury/illness (Auto, Slip and Fall, Malpractice, or describe other)

Attorney involvementIndicate if you have sought assistance of an attorney; if Yes provide attorney name, mailing address, and phone number