Dhs 1125a assignment payment form pdf 2026

1. Click ‘Get Form’ to open the DHS 1125A Assignment Payment Form in the editor.
2. Begin by filling in the 'Name of Injured' section, including last name, first name, middle initial, case number, and ID number.
3. Provide the date of the accident and application date. Ensure you also include the medical eligibility date for accurate processing.
4. Select the type of accident from the options provided (e.g., Auto, Bicycle). This helps categorize your claim appropriately.
5. In the description fields, clearly outline how the accident occurred, including time and location. Detail the type and extent of injuries sustained.
6. List any medical professionals involved in treatment under 'Beneficiary treated/seen by'. Include names and contact information for thoroughness.
7. Indicate whether there is ongoing medical care required for the beneficiary's injury by selecting YES or NO.
8. Complete sections regarding potential fault and insurance details. This includes providing information about other parties involved in the accident.
9. Finally, review all entries for accuracy before saving or submitting your completed form through our platform.

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