NCSRCCHF Claims

payment or Security

Member's Full Name

First

Last

Last 4 Digits of Social Security Number

Date of Birth

Address

Address Line 1

City

State

Zip Code

Phone

Patient's Full Name

First

Last

Relationship to Member

Date of Birth

Date of Injury

Where Did the Injury Occur?

(City, State, Whose Property?

Describe How the Injury Occurred

Did the Injury Occur As a Result of a Job for Which You Were Paid?

If "Yes", Please List Your Most Recent Employer

Has there been, or will there be worker’s compensation claim filed for this injury?

Is it possible that a third party may be responsible for payment of a portion or all of the medical expense?

If "Yes", please indicate the name and address of the third party.

If known, please identify the third party’s insurance carrier and claim number.

Acknowledgement

I hereby certify that that the statements hereon and attached are complete and accurate, and I authorize any person or institution rendering care, or any person or organization in possession of insurance or other benefit information concerning me or my dependents, to furnish and disclose all known facts and data concerning the subject injury to the North Central States Regional Council of Carpenters Health Fund as well as to any cost containment organizations and entities retained by or authorized by the Trustees.

Date