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Understanding the important details of the BCBSM Subrogation form is essential for anyone navigating the complexities of insurance claims related to personal injuries or related cases. This form, designed specifically for Blue Cross Blue Shield of Michigan clients, captures vital information needed for the subrogation process. It requires essential details like the client's name, date of birth, and contract number, which can be found on the BCBSM card. The form also inquires about the nature of the case, whether it involves personal injury, product liability, medical malpractice, workers’ compensation, or motor vehicle accidents. Additionally, it asks for the relevant state details regarding the incident and information about the liable party. Legal representation details such as the attorney's name, law firm, and contact information are key components of this form. Clients must ensure that their insurance information, including the adjuster's contact details, is accurate to avoid delays. Completing the BCBSM Subrogation Unit Questionnaire efficiently is crucial, as timely submission can expedite the claims process. Be mindful that all forms must be faxed to (877) 257-2012, ensuring a clear line of communication with the Subrogation Department.

Bcbsm Subrogation 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

Form Characteristics

Fact Name Description
Issuing Office The form is issued by the Office of the General Counsel Subrogation Department located at 232 S. Capitol Ave., L09A, Lansing, Michigan 48933-1504.
Contact Information For inquiries, contact (517) 325-4658 or fax to (877) 257-2012. Email can be sent to SubrogationUnit@bcbsm.com.
Purpose This questionnaire is used to gather information related to subrogation cases involving BCBSM policyholders.
Client Information The form requires detailed information about the client, including name, date of birth, and contract number.
Type of Cases Selectable options for the type of case include personal injury, product liability, medical malpractice, workers’ compensation, and motor vehicle accidents.
State Information Applicants must specify the state where the incident occurred and the state in which the liable party resides.
Attorney Details The form requires information about the attorney representing the client, including their name, law firm, and contact details.
Insurance Details Information about the insurance company involved, including the insurance adjuster's name and claim number, must be provided.
Next Hearing Date Applicants are required to provide the date and type of the next scheduled hearing related to the case.

Guidelines on Utilizing Bcbsm Subrogation

After completing the Bcbsm Subrogation form, the next step involves submitting it to the Blue Cross Blue Shield of Michigan Subrogation Unit via fax. Ensure all required information is filled accurately. This can help expedite the processing of your case.

  1. Begin by providing the date at the top of the form.
  2. Enter your full name as the client.
  3. Fill in your date of birth.
  4. Locate and provide your contract number, which is a 9-digit number found on your BCBSM card.
  5. If applicable, add your spouse's name, along with their date of birth.
  6. State the BCBSM policy holder’s name, if different from yours.
  7. Include your phone number for contact purposes.
  8. Select the type of case applicable to you from the provided options.
  9. Indicate where the incident occurred by naming the state.
  10. Specify the state where the liable party resides.
  11. Answer whether a vehicle was involved in the incident (Yes or No).
  12. If applicable, note the venue or jurisdiction related to your case.
  13. Provide the date of the injury.
  14. Describe the type of injury and the area of the body that was injured.
  15. Fill in the attorney’s name and law firm details.
  16. Add the attorney’s street address, city, state, and zip code.
  17. Include the attorney's phone number and fax number.
  18. Report the insurance company’s name and the adjuster's name.
  19. Input the insurance claim number.
  20. Provide the insurance company's address, including street, city, state, and zip code.
  21. Fill in the adjuster's phone number and fax number.
  22. Finally, document the date and type of the next scheduled hearing.
  23. Once completed, fax the form to 877-257-2012.

What You Should Know About This Form

What is the BCBSM Subrogation Form?

The BCBSM Subrogation Form is used to collect information related to claims where another party may be responsible for your injury. It helps Blue Cross Blue Shield of Michigan determine if you are entitled to reimbursement for medical expenses covered by your insurance when someone else's actions led to those expenses.

Who should complete the Subrogation Form?

The form should be completed by the client who received medical treatment covered by BCBSM. If applicable, a spouse can also fill out the form if they are enrolled in the same policy. Ensure to include all necessary details about the injury and the liable party.

When should I submit the Subrogation Form?

You should submit the form as soon as possible after your injury and after seeking medical attention. Timely submission can help expedite the recovery process of any claims for reimbursement.

Where do I send the completed Subrogation Form?

Fax the completed form to the BCBSM Subrogation Unit at (877) 257-2012. You may also reach out via email at SubrogationUnit@bcbsm.com for any questions before submission.

What information is required on the Subrogation Form?

The form requires details such as your name, date of birth, contract number, the nature of the case, attorney information, insurance company details, and specifics about the incident, including the type of injury and involved parties.

Are there any specific cases that require a Subrogation Form?

Yes, the form is applicable to personal injury cases, product liability, medical malpractice, workers’ compensation (specifically in Michigan), motor vehicle accidents, and motorcycle accidents, among others. Provide clear information on the type of case you are filing.

What if I have more questions about the form or process?

If you have additional questions, you can contact the BCBSM Subrogation Unit directly at (517) 325-4658. They can provide guidance and clarify any uncertainties you may have about completing the form or the subrogation process.

Can I submit this form by email?

Form submission is preferred via fax. However, if you need clarification first, feel free to email your inquiries to SubrogationUnit@bcbsm.com. Make sure to keep any sensitive information secure.

What happens after I submit the Subrogation Form?

After submission, BCBSM will review your case. They will assess whether they can recoup costs from the liable party. You may be contacted for additional information if needed. Stay in touch with your attorney and BCBSM for updates on your case.

Common mistakes

Filling out the BCBSM Subrogation Form can be a straightforward task, but many individuals make common mistakes that can complicate the process. One frequent error is omission of essential information. Users often neglect to provide complete details, such as the full name or date of birth of the client and the policyholder. This lack of completeness can lead to delays or rejections.

Another prevalent mistake involves incorrect contact information. People sometimes input inaccurate phone numbers or email addresses for themselves or their attorneys. Ensure all contact details are correct and up-to-date to facilitate smooth communication with BCBSM's Subrogation Unit.

Choosing the wrong type of case can also hinder the process. The form specifically requires a selection among categories like personal injury, medical malpractice, or motor vehicle accident. If the case doesn't adequately match any of these categories, it may lead to confusion or additional scrutiny, ultimately slowing down the progress of the claim.

Inaccuracies regarding the geographic details of the case frequently occur. Individuals occasionally provide mismatched states for where the incident took place versus where the liable party resides. This discrepancy can complicate the navigating of legal jurisdictions and impact the claim's outcome.

Not providing the necessary attorney information constitutes another common error. The form requires clear details about the attorney representing the client, including their name, law firm, and contact information. Failing to include this crucial data can create barriers in the processing of the subrogation claim.

Individuals sometimes overlook the requirement to include insurance details, such as the insurance claim number and the adjuster's contact information. Omitting this section can stall the process since BCBSM needs these details to coordinate with the relevant insurance companies.

Submitting a non-compliant or invalid form is a mistake that can be easily avoided. Make sure to review the entire form for adherence to specified guidelines and formatting rules. If the form is faxed with legibility issues or does not include all pertinent information, it could be rejected, prompting the need to start over.

Finally, neglecting to keep a copy of the submitted form can lead to complications later. Retaining a copy ensures that individuals have a record of what was submitted and can reference it if additional information is needed or if follow-up is required. Being thorough and attentive to detail can greatly increase the chances of a smooth subrogation process.

Documents used along the form

When dealing with a subrogation claim, several forms and documents accompany the BCBSM Subrogation Form to ensure a comprehensive and efficient processing of your case. Each document plays a vital role in gathering necessary information and supporting your claim. Here’s a list of commonly used documents alongside the BCBSM Subrogation Form:

  • Subrogation Demand Letter: This letter initiates the subrogation process, outlining the insurer's claim against the liable party for reimbursing costs related to the injury or loss.
  • Insurance Policy Documents: These documents provide details about the coverage terms, conditions, and limits related to the injured party's policy, essential for determining liability.
  • Medical Records: Complete medical records are necessary to substantiate the injuries claimed and demonstrate the related medical expenses incurred.
  • Proof of Expenses: Receipts and invoices for medical bills, rehabilitation, and any other related expenses should be compiled and submitted to support the claim.
  • Incident Report: A report that details the circumstances of the accident or injury, helping to establish liability and provide context for the claim.
  • Witness Statements: Written accounts from individuals who witnessed the incident can significantly bolster the case by confirming key details and events.
  • Legal Representation Agreement: This document outlines the agreement between the client and the attorney, clarifying fees and responsibilities in pursuing the claim.
  • Liability Insurance Information: Details about the liable party’s insurance coverage are necessary for pursuing subrogation effectively, indicating the available resources for recovery.
  • Claim Form from Liable Party's Insurer: This form is often required to formally notify the liable party's insurance of the claim and request reimbursement.
  • Discharge of Liens: If there are any liens filed against the settlement, this document ensures that all parties are aware and releases claims or rights to recovery.

Collecting and submitting these documents alongside the BCBSM Subrogation Form will facilitate a more streamlined process. Ensure all information is accurate and complete to enhance the likelihood of a successful recovery. Your diligence is pivotal in navigating the complexities of such claims.

Similar forms

The Bcbsm Subrogation form serves specific purposes related to recovery of costs in legal situations. Other documents share similarities in their intent and use. Here are seven documents similar to the Bcbsm Subrogation form:

  • Medical Authorization Form: This document permits healthcare providers to release medical records to involved parties. Both forms require detailed personal and case information.
  • Liability Release Form: This form releases one party from liability concerning a specific incident. Like the subrogation form, it often includes information about the nature of the injury and the parties involved.
  • Claimant Questionnaire: This document gathers information from individuals seeking claims. It addresses similar types of injuries and requires specifics about the incident, much like the subrogation form.
  • Insurance Claim Form: This form is submitted to notify an insurance company of a claim. It collects relevant details about the incident, the parties involved, and the type of claim, paralleling the information required in the subrogation form.
  • Incident Report: This report documents the specifics of an accident or injury. Both the incident report and the subrogation form include critical data points regarding the event and the individuals involved.
  • Personal Injury Demand Letter: This letter outlines a person's injuries and demands compensation. While its tone may be more assertive, it still shares the essential need for accurate information about the case.
  • Workers' Compensation Claim Form: Used to claim benefits after a workplace injury, this form includes data about the injury and employer details, similar to what's needed in the subrogation scenario.

Dos and Don'ts

When filling out the BCBSM Subrogation form, there are important do's and don'ts to keep in mind. Here’s a simple list to guide you:

  • Do ensure all personal information is accurate, including names and birth dates.
  • Do select the correct type of case that relates to your situation.
  • Do provide detailed information about the liable party and their insurance.
  • Do include your attorney’s contact information, if applicable.
  • Do double-check that the form is complete before faxing.
  • Don't leave any sections blank; missing information can delay processing.
  • Don't use unfamiliar terms or jargon that could confuse those reviewing the form.
  • Don't submit a handwritten form; it should be typed for clarity.
  • Don't forget to verify the fax number before sending the completed form.
  • Don't send the form without keeping a copy for your records.

By following these do's and don'ts, you can ensure that your form is filled out correctly and expediently processed.

Misconceptions

  • Misconception 1: The subrogation form is only for personal injury cases.

    This is not true. While personal injury cases are included, the form can also be used for other types of claims such as product liability, medical malpractice, workers' compensation, and motor vehicle accidents. It's important to select the correct type of case when completing the form.

  • Misconception 2: You cannot submit the form without an attorney.

    This is misleading. While having legal representation is beneficial, you can complete and submit the subrogation form independently. The form is designed to collect necessary information, regardless of whether you are working with an attorney.

  • Misconception 3: The subrogation process is always lengthy and complicated.

    This varies based on individual circumstances. While some cases may require more time and paperwork, many subrogation claims can be resolved efficiently. Providing accurate and complete information on the form can help streamline the process.

  • Misconception 4: You must wait until after your case is resolved to submit the form.

    This is incorrect. You should submit the subrogation form as soon as possible, even if your case is still in progress. Early submission can facilitate the process and may lead to quicker reimbursement from the liable party's insurance.

Key takeaways

When it comes to the BCBSM Subrogation form, there are a few important points to keep in mind to ensure a smooth process.

  • Accurate Information is Essential: Make sure to fill in all required fields correctly, such as the client’s name, date of birth, and contract number from the BCBSM card. Errors can delay the processing of your submission.
  • Understanding the Types of Cases: Be sure to select the appropriate type of case from the provided options. This helps the subrogation unit to identify the nature of your claim efficiently.
  • Communication is Key: Include all relevant contact details for your attorney and insurance adjuster. This aids in swift communication between all parties involved, ensuring everyone is on the same page.
  • Follow Submission Instructions: Remember to fax the completed form to the specified number, which is 877-257-2012. Proper submission will help to expedite your case review.

By following these guidelines, you will enhance the likelihood of your form being processed promptly and accurately.