INJURED PERSON'S INFORMATION | Long Branch High School

Injured Person's Information

THE INJURED PERSON'S SOCIAL SECURITY NUMBER MUST BE PROVIDED AS REQUIRED BY THE CENTER FOR MEDICARE SERVICES.

Injured Person's Social Security Number: *

Injured Person's Home Address (Street, City, State, Zip): *

Is the Injured person Employed?: *

Yes

If yes, please fill out Section A below.

Is the Injured Person Married?: *

Yes

Spouse's Name: *

Is the Spouse Employed?: *

Yes

If yes, please fill out Section B below.

Are you covered by any other insurance policy, either as a dependent, group, individual, automobile medical or liability:

Yes

If Yes: Name of Insurance Carrier: *

Policy #: *

Parent/Guardian Information

Father/Guardian Name: *

Address (Street, City, State, Zip): *

Home Phone: *

Is the Father Employed?:

Yes

Mother/Guardian Name: *

Address (Street, City, State, Zip): *

Home Phone: *

Is the Mother Employed?: *

Yes

MEDICAL INFORMATION AUTHORIZATION ASSIGNMENT OF BENEFITS:

You are hereby authorized to furnish at the request of and to BMI Benefits, LCC or the underwriting companies with which it works, information which you may possess; including findings and treatment rendered, X-rays and copies of all hospital and medical records, all occasioned by professional services and hospital care rendered on my behalf. The foregoing authorization is granted with the understanding that any legal rights I may ordinarily have to claim communications between us as privileged are hereby expressly and voluntarily waived. A photostat of this authorization shall be considered as effective and valid as original. PAYMENT WILL BE MADE TO THE PROVIDERS OF SERVICE (HOSPITAL, PHYSICIAN AND OTHERS), UNLESS A PAID RECEIPT OR STATEMENT ACCOMPANIES THE BILL AT THE TIME THE CLAIM IS SUBMITTED.

NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Claimant or Authorized Person's Signature: *

Date: *

Month

Day

Year

BOB MCCLOSKEY INSURANCE/BMI BENEFITS L.L.C.

Parent’s Instructions for Filing a Claim:

The school accident claim form must be completed in full and signed by the appropriate school official. This includes all the accident information, parent/guardian insurance information (including parent’s employment information and health insurance information), student’s social security number and parent/guardian signature on the claim form where it indicates “Medical Information Authorization Assignment of Benefits”.
If you are employed but have no insurance, please include a statement on your companies letterhead stating there is no dependent health insurance coverage. If you have Medicaid or Tricare, please submit a copy of your identification card.
Please submit itemized bills to BMI Benefits LLC (HCFA 1500 form from physicians and UB-04 form from hospitals) along with a copy of the explanation of benefits from your primary health insurance. BMI Benefits LLC cannot process bills from billing statements that patients receive ion the mail. Please note that if you advise providers that BMI Benefits LLC is the secondary insurance on your child’s claims then they should bill them directly after your health insurance makes payment
Please be sure to include the copies of receipts for any payments you made to providers. In order to reimburse any payments that are made by parents/guardians, BMI Benefits LLC will need the itemized bills and explanation of benefits (as mentioned above).