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CRYSTAL OAKS GROUP HEALTH PLAN ACCIDENT QUESTIONNAIRE

CRYSTAL OAKS GROUP HEALTH PLAN ACCIDENT QUESTIONNAIRE 2025

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The document is a questionnaire for members of the Crystal Oaks Group Health Plan to complete regarding an accident or injury related to a claim. It requests detailed information about the accident, including dates, locations, circumstances, and any legal actions taken. The completed form must be returned to Mercy Benefit Administrators to facilitate the processing of claims.

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Click ‘Get Form’ to open the CRYSTAL OAKS GROUP HEALTH PLAN ACCIDENT QUESTIONNAIRE in our editor.
Begin by entering your MEMBER NAME and MEMBER ID # at the top of the form. This information is crucial for processing your claim.
Indicate whether the date of service was related to an accident/injury by selecting 'YES' or 'NO'. If 'NO', provide a brief explanation in the designated area.
If you answered 'YES', fill in the date of the accident/injury, location details, and a comprehensive description of how it occurred.
Answer questions regarding employment-related injuries, witnesses, and any police reports. Ensure to provide all requested details accurately.
Complete the authorization section at the end of the form by signing and dating it. If applicable, have the claimant sign as well.

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2016	4.8 Satisfied (41 Votes)

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