Accident Claim Form - Housatonic Valley Regional High School 2025

1. Click ‘Get Form’ to open the Accident Claim Form in our editor.
2. Begin by entering the Member Name, SSN, and DOB in the designated fields at the top of the form.
3. Fill in the Policy number and Adjuster’s name as required. Ensure all information is accurate to avoid processing delays.
4. In Section 2, check the appropriate boxes for the type of information you authorize for disclosure. Include any additional relevant details.
5. Complete Section 4 by providing the name and address of individuals or organizations that will receive this information.
6. Specify the purpose of disclosure in Section 5, which is typically for processing health insurance claims.
7. Sign and date the form at the bottom. If signed by a legal representative, indicate their relationship to the patient.

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