Medicaid Subrogation Form

For receiving assistance from Medicaid, the Medicaid Subrogation Form has to be completed and submitted.

Extracted Text for Proper Search

MEDICAID SUBROGATION REQUEST FORM 	
 
REFERRING ATTORNEY/INSURANCE CO.:____________________________________________________ 
ADDRESS:   ____________________________________________________________________________ 
TELEPHONE NO:  __ ____________________________ FAX NO:  _________________________________ 
************************************************************************************* 
1.  CLIENT NAME : ______________________________________________________________________ 
2.  DATE OF BIRTH: _ __________________________  DATE OF ACCIDENT: _________________________ 
3.  SS#: ______________________________________ MID#:  ___________________________________ 
4.  POLICE REPORT ATTACHED    YES _______________________  NO______________________________ 
5.  PETITION ATTACHED :               YES _______________________  NO_____________________________ 
6.  INJURIES 1.________________________________ 3.______________________________________ 
                       2.________________________________ 4._______________________________________ 
7.  TREATING HEALTH CARE PROVIDERS 
                         1. _______________________________ 3 _______________________________________ 
                          2._______________________________ 4 _______________________________________ 
8.  INSURANCE COMPANY:  _______________________________________________________________ 
              CLAIM/POLICY NO.:  _______________________________________________________________ 
              ADJUSTER/PHONE#: _____________________________________________________________ __ 
              ATTORNEY/PHONE#: ______________________________________________________________ 
9.  MEDIATION DATE: __ _________________________ARBITRATION DATE: __ _____________________ 
     SETTLEMENT DATE: _ _________________________TRIAL DATE:  ______________________________ 
10.  NOTES/COMMENTS:  ______________________________________________________________ __ 
__ ___________________________________________________________________________________ 
__ ___________________________________________________________________________________ 
__ ___________________________________________________________________________________