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Statement of Personal Injury – Possible Third Party Liability

Claims submitted with ICD-10-CM S and T diagnosis codes or ICD-9-CM 800–999 diagnosis codes for professional services exceeding $500 and inpatient services often indicate an accidental injury or illness. When filing these claims, the provider needs to have the beneficiary complete the Possible Third Party Liability form.

Fax form to: 1-844-869-2813

 

Tip: If you are unable to open the form using the link above, hover over "View >>" below, right click and select "Save link as." 

  • Created: Aug 1, 2022
  • Modified: Jul 5, 2022
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