Questionnaire

Welcome to the Ingenix on-line injury questionnaire. At Ingenix, we understand that filling out forms and returning phone calls can be a hassle. We have designed this on-line questionnaire to assist you, and hopefully make the process a little less time consuming and inconvenient. With your help, we will be able to obtain the information needed to process your medical claims.

Ingenix File Number:*
Member's Full Name:*
Patient's Full Name:*
Patient Street Address:*
City:*  State:*     Zip:*  
Home Number:* (area code required)
Work Number:
* Required fields


Were the charges indicated related to an accident/injury?  Yes  No
If NO, date condition started:
Please describe condition:
If YES, complete questionnaire.
Are you still being treated?  Yes  No
How did the accident/injury occur? (Describe in detail):
Where did the accident/injury occur? (Location):
When did the accident/injury occur? (Date and time):
Are the charges due to an injury/sickness related to employment?  Yes  No
If YES, have the charges been filed with the workers compensation carrier?  Yes  No
Workers Compensation Carrier:
Address:
Phone Number:
Carrier's Policy Number:
Claim Number:
If workers compensation benefits were denied, please send a copy of the denial letter to Ingenix.


If the charges indicated above are related to a MOTOR VEHICLE ACCIDENT, we need the following:
YOUR Auto Insurance Company Name:
Address:
Phone Number:
Policy #:
Claim #:
Policy Holder:
OTHER PARTY'S Name:
Address:
Phone Number:
Auto Insurance Company Name:
Address:
Phone Number:
Policy #:
Claim #:
Was a police report made?  Yes  No
Name of Police Department:


If the charges are related to a NON MOTOR VEHICLE ACCIDENT, please list the property owner's
Name:
Address:
Phone Number:
Premise Insurance Information:


Additional Comments: