spacer
Anthem Blue Cross Blue Shield Health Insurance  
eSubrogation Questionnaire Need Help?

We welcome your questions and comments. At Anthem, we are dedicated to providing acurate, helpful information, so each inquiry is directed to a qualified specialist who will respond as quickly as possible.

In order to ensure confidentiality is protected, some responses will not be sent via internet e-mail. For inquiries requiring confidentiality, please provide either your phone number or mailing address so we can discreetly respond to your question.

 Required field.

  Please enter the following information from our Subrogation Questionnaire  
 
Policy Holder Name:        (first, mi, last)
Patient Name:        (first, mi, last)
Date of Service: / /    (mm/dd/yyyy)
Case Number:
The case number is listed on your correspondence.
Subscriber Identification Number:
Email:
At least one phone number must be supplied.
Day Phone: ( - 
Evening Phone: ( - 
If you are unsure whether the care was due to an accidental injury where another person, employer or insurance company may be responsible for payment of the medical services, please call us at 1-866-891-7397, Monday - Friday 9:00 AM to 4:00 PM ET.
 
  Was the care provided for the services noted on the Subrogation Questionnaire a result of a WORK RELATED injury or illness?  
 
Yes      No
 
  Was the care provided for the services noted on the Subrogation Questionnaire due to accidental injury where ANOTHER person or insurance company may be responsible for the payment of the medical services?  
 
Yes      No
 
  Was the care provided for the services noted on the Subrogation Questionnaire due to an accidental injury that was YOUR fault?  
 
Yes      No
 
 
 
Please click here to complete this section if this is a result of a WORK RELATED injury or illness.

Workers' Compensation Section

Briefly describe the accident
Did you report condition to employer?
Yes      No
Is patient self-employed?
Yes      No
Have you filed a Workers' Compensation claim?
Yes      No
Was your Worker' Compensation claim approved?
Yes      No      Pending
Employer Details
Employer Name:
Address:
City:
State:
Zip:
Workers' Compensation Insurance Company Details
Name:
Address:
City:
State:
Zip:
Claim Number:
Approvals Board Number:
Adjuster Name:        (first, mi, last)
Phone:
Do you have an attorney?
Yes      No
Attorney Details:
Attorney Name:
Address:
City
State:
Zip:
Phone:
Please click here to complete this section if the services noted were due to an accidental injury or incident where ANOTHER person or insurance company may be responsible for the payment of the medical services

Accident Details

Motor Vehicle Accident Details
Single Vehicle
Multiple Vehicle
Other Type Accident
Briefly describe the accident
If you have any questions or need assistance please call us at 1-866-891-7397, Monday - Friday 9:00 AM to 4:00 PM ET.
Was the other person at fault? Yes      No
Has a settlement been reached? Yes      No
Responsible Party Insurance Information
Driver Name:
(if auto accident)
       (first, mi, last)
Policy Holder Name:        (first, mi, last)
Insurance Company:
Address:
City:
State:
Zip:
Claim Number:
Adjuster Name:        (first, mi, last)
Phone:
Vehicle in which patient was a driver or passenger
Insurance Company:
Phone:
Claim or Policy Number:
Do you have an attorney?
Yes      No
Attorney Details:
Attorney Name:
Address:
City
State:
Zip:
Phone:
Please click here to complete this section if the services noted on the Subrogation Questionnaire are due to an accidental injury that was YOUR fault

Your Insurance Details

Insurance Company:
Address:
City:
State:
Zip:
Phone:
Policy Number:
Agent Name:        (first, mi, last)

 

   clear button

 

®Registered marks Blue Cross and Blue Shield Association
©2005 copyright of Anthem Insurance Companies, Inc.


Health insurance

for individuals, families & employers. Find Anthem Blue Cross Blue Shield health and medical insurance information for visitors, members, individuals & families, employers, brokers & producers. Learn about group health insurance plans, family & individual insurance options, health insurance savings accounts, obtain a health insurance quote.

Anthem Blue Cross and Blue Shield

is the trade name for the following: In Connecticut: Anthem Health Plans, Inc. In Colorado, Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky. In Maine: Anthem Health Plans of Maine, Inc. In Missouri: RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC) and HMO Missouri, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi) and Compcare Health Services Insurance Corporation (Compcare). Independent licensees of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri, Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use.

Investor relations – information on WellPoint, Inc., formerly Anthem, Inc.