Umr acts of third party subrogation inquiry form 2025

1. Click ‘Get Form’ to open the umr acts of third party subrogation inquiry form in the editor.
2. Begin by filling out Section B, Employee Information. Enter your identification number, plan year, employer details, and contact information including phone and email.
3. In Section C, Health Care Expenses, list the dates of service, provider names, types of services received, and the amounts requested for reimbursement. Ensure all entries are accurate and itemized.
4. Review Section D for Certification. Confirm that all expenses meet the outlined conditions and provide your signature along with the date.
5. Attach any required documentation such as itemized bills or explanation of benefits (EOB) before submitting your completed form through our platform.

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