Questionnaire - Harvard Pilgrim Health Care 2025

1. Click ‘Get Form’ to open the Questionnaire - Harvard Pilgrim Health Care in the editor.
2. Begin by entering your Member Name, HPHC ID, and Date of Service at the top of the form.
3. Indicate if the injury/illness was related to an Auto/Motorcycle Accident, Work/Industrial Accident, or No Accident by checking the appropriate box.
4. If applicable, fill out Sections 1, 2, and 4 for Auto/Motorcycle related incidents or Sections 1, 3, and 4 for Workers' Compensation claims. If there is no other party liable, check 'No Accident' and complete Section 1.
5. In Section 1, provide details about the date and location of the injury/illness along with a brief description of how it occurred. Answer whether you are still being treated for this injury.
6. For Section 2, if applicable, specify your role in the accident (Pedestrian, Passenger, Driver) and provide insurance information as required.
7. Complete Section 3 if this was a Work/Industrial Accident by providing employer details and any Workers’ Compensation claim information.
8. Finally, in Section 4, indicate if you are represented by an attorney and provide their contact information. Sign and date the form before submission.

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