Fill and Sign the 12285 Mandatory Disclosures Family Florida Form

SEE REVERSE SIDE FOR CLAIM FILING INSTRUCTIONS 1. Report school related injuries to the school within 72 hours 2. Complete this form 3. Attach all bills 4. Mail to STUDENT INSURANCE CLAIM FORM myers • stevens & toohey & co., inc. 26101 marguerite parkway mission viejo, california 92692-3203 (949) 348-0656 • fax (949) 348-2630 Beech Street Corporation CLAIMANT INFORMATION PART A NAME OF INSURED PERSON FIRST MI LAST STUDENT SOCIAL SECURITY # – NAME OF SCHOOL NAME OF SCHOOL DISTRICT ADDRESS OF SCHOOL / DAY / STUDENT I.D. # FROM I.D. CARD ᮤ GRADE TIME OF INJURY YR : A.M. / P.M. (CIRCLE ONE) OR ᮣ DATE OF BIRTH ■ FEMALE ■ MALE CITY DATE OF INJURY/SICKNESS MO AGE – MO / STATE INJURY OCCURRED: ■ Interscholastic Practice PLEASE ✔ ONE ■ At Home ■ Interscholastic Game ■ Intercollegiate Sport ■ Field Trip ■ P.E. ■ Classroom DAY / YR ZIP CODE TYPE OF SPORT ■ Travel ■ Other______________________ DETAILS OF SICKNESS OR HOW THE INJURY OCCURRED. PLEASE BE SPECIFIC (NOTE: IF YOUR SCHOOL USES AN WAS STUDENT PARTICIPATING IN SPORT NOT SCHOOL-RELATED? ACCIDENT REPORT FORM, PLEASE ATTACH A COPY OF THE REPORT ALSO). (IF YES, LIST NAME AND PHONE NO. OF GROUP) ■ YES ■ NO WHAT PART OF THE BODY WAS INJURED? HAS THE STUDENT SUFFERED FROM SAME OR SIMILAR CONDITION BEFORE? ■ YES ■ NO IF YES, WHEN? NAME, ADDRESS AND PHONE NO. OF INSURED’S FAMILY PHYSICIAN CITY STATE ZIP CODE TELEPHONE NO. ( ) COMPLETE THE FOLLOWING ONLY IF INJURY IS SCHOOL RELATED NAME OF SCHOOL SUPERVISOR DATE SCHOOL WAS NOTIFIED OF ACCIDENT WAS HE/SHE A WITNESS TO THE ACCIDENT? ■ YES NAME OF SCHOOL OFFICIAL SIGNATURE OF SCHOOL OFFICIAL (REQUIRED ONLY IF SCHOOL RELATED) DATE SIGNED ( X CLAIMANT, PARENT OR GUARDIAN STATEMENT PART B RELATIONSHIP TO INJURED ■ SELF ■ FATHER ■ NO SCHOOL TELEPHONE NO. ) (PLEASE PRINT OR TYPE CLEARLY) IS THIS DEPENDENT COVERED BY OTHER HEALTH AND/OR ACCIDENT INSURANCE PLAN? ■ MOTHER ■ LEGAL GUARDIAN NAME OF CLAIMANT (IF ADULT), OR LEGAL MALE GUARDIAN ■ OTHER ■ YES ■ NO HOME TELEPHONE NO. S.S. # OF LEGAL MALE GUARDIAN ( ADDRESS CITY NAME OF EMPLOYER ZIP CODE WORK TELEPHONE AND EXTENSION NO. ( ADDRESS OF EMPLOYER ) STATE ) CITY NAME OF OTHER HEALTH AND/OR ACCIDENT INSURANCE COMPANY THROUGH LEGAL MALE GUARDIAN STATE POLICY NUMBER ZIP CODE TELEPHONE NO. ( ADDRESS OF INSURANCE COMPANY NAME OF LEGAL FEMALE GUARDIAN CITY ) STATE ZIP CODE HOME TELEPHONE NO. S.S. # OF LEGAL FEMALE GUARDIAN ( ADDRESS CITY NAME OF EMPLOYER ) CITY NAME OF OTHER HEALTH AND/OR ACCIDENT INSURANCE COMPANY THROUGH LEGAL FEMALE GUARDIAN STATE POLICY NUMBER CITY STATE I understand that 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 facts material thereto commits a fraudulent act, which is a crime, and may subject such person to fines and/or imprisonment. I hereby authorize any school authority, trust fund, employer, insurance company or person who has attended or examined the claimant to disclose to Myers-Stevens & Toohey & Co., Inc., when requested to do so, any information regarding any injury, illness, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records and itemized bills, and to pay benefits based upon this information. A photostatic copy of this authorization shall be considered as valid and effective as the original. ZIP CODE TELEPHONE NO. ( ADDRESS OF INSURANCE COMPANY ZIP CODE WORK TELEPHONE AND EXTENSION NO. ( ADDRESS OF EMPLOYER ) STATE ) ZIP CODE CLAIMANT, PARENT OR LEGAL GUARDIAN SIGNATURE X RELATIONSHIP TO CLAIMANT DATE AUTHORIZATION TO PAY BENEFITS TO PROVIDER. I authorize payment of Medical payments to Physician or Supplier for Services on the attached. SIGNATURE OF PARENT OR LEGAL GUARDIAN 108 REV. 03/04 VOL PPO/SHC/FHC/MAND R&C ALL STATES DATE CLAIM FILING PROCEDURE ❶ Report school related injuries to the school within 72 hours. ❷ Have school complete PART A. (Parents may fill out PART A if injury is not school related.) ❸ Claimant, parent or guardian complete PART B. ❹ IMPORTANT: Both parts must be completed in full or claim will not be processed. ❺ Mail form to our office with all itemized bills within 90 days of the first date of treatment. ❻ At the same time, please file a claim with your other family health and/or accident carrier. This can include employee plans, union plans, CHAMPUS (military plans), service contracts, self-insured benefit plan, or health maintenance organizations (HMO’s). ❼ When you receive a notice of payment, a notice of denial, or a letter stating you have met your deductible from your other health and/or accident carrier, please forward this information to our office. ➑ If you have any questions, please call our office at 949-348-0656. NON-DUPLICATION OF BENEFITS: (Not applicable in Oregon) In order to keep premiums as affordable as possible, these plans pay benefits on a non-duplicating basis. This means, if a person is covered by one or more of our plans and by any other valid insurance or health agreement, any amount payable or provided by the other coverages will be subtracted from the covered expenses and we will pay benefits based on the remaining amount. COMMONLY ASKED QUESTIONS ❶ Do I have to go to a specific doctor or hospital? No, you can go to the doctor or hospital of your choice. *However, if you go to a doctor or hospital that is part of the Beech Street preferred provider network, you may have your out-of-pocket expenses significantly reduced. To find a participating doctor or hospital in your area, call 800-877-1666, 24-hours a day, 7-days a week or log on to www.beechstreet.com. * Does not apply to Family Health Care Coverage or where prohibited by law. ❷ Do I need to attach a claim form for each bill? No, only one claim form is required per injury or sickness. In the states of: AZ, CA and NV Underwritten by: In the states of: AK, CO, ID, NM, OR, WA, UT Underwritten by: myers • stevens & toohey & co., inc. 26101 marguerite parkway mission viejo, california 92692-3203 (949) 348-0656 fax (949) 348-2630 For residents of California and Texas: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.