Statement of Personal Injury - Possible Third Party Liability
This form is used to collect information to determine third-party liability for injuries requiring medical care. It allows the United States to recover medical expenses from the party responsible for the injury. Failure to complete this form will result in delays or denial of your TRICARE claim.
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How do I fill this out?
To fill out this form, you will need to provide detailed information about the injury, including the circumstances, parties involved, and medical care received. Make sure to complete all sections accurately to avoid delays in processing your TRICARE claim. Follow the instructions carefully and consult a legal advisor if you have any questions.
How to fill out the Statement of Personal Injury - Possible Third Party Liability?
1
Gather all the required information, including details of the injury and parties involved.
2
Complete Section I with general information about the injured patient.
3
Fill out Section II with the type and cause of the injury.
4
Provide additional details in Section III, such as military medical facilities, lawyer information, and insurance coverage.
5
Sign and date the form, then return it as instructed.
Who needs the Statement of Personal Injury - Possible Third Party Liability?
1
TRICARE beneficiaries who have suffered an injury requiring medical care.
2
Individuals involved in accidents or incidents where a third party may be liable.
3
Military personnel and their dependents covered by TRICARE.
4
Legal representatives assisting clients with TRICARE claims.
5
Healthcare providers processing TRICARE claims for injured patients.
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Open the PDF in the editor and add or modify text in the designated fields.
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What are the instructions for submitting this form?
Return the completed form to the TRICARE processor who sent you the form, or to the TRICARE claims processor for the state/country where you received medical care. If no preaddressed envelope is provided, consult the Health Benefits Advisor at your nearest military installation for submission addresses. For assistance, contact a Judge Advocate office or call the toll-free number provided in the form.
What are the important dates for this form in 2024 and 2025?
The form must be submitted within 35 days from the date of the letter. It is valid until 31 July 2025.
What is the purpose of this form?
The Statement of Personal Injury - Possible Third Party Liability form is used to collect information necessary to determine when third-party liability exists for injuries requiring medical care. The purpose of this form is to allow the United States to recover medical expenses from the party responsible for the injury. By providing accurate information, beneficiaries help ensure their TRICARE claims are processed efficiently and without delays.
Tell me about this form and its components and fields line-by-line.
- 1. Sponsor's Social Security Number: The social security number of the TRICARE sponsor.
- 2. Injured Patient's Name: The name of the injured TRICARE beneficiary.
- 3. Injured Patient's Address: The residential address of the injured TRICARE beneficiary.
- 4. Date Injury Occurred: The date and approximate time when the injury occurred.
- 5. Locality and State Where Injury Occurred: The location and state where the injury took place.
- 6. Type and Cause of Injury: Details about the type of injury and the circumstances that caused it.
- 7. List of Military Medical Facilities: Military medical facilities that provided care for the injury and dates of treatment.
- 8. Lawyer Information: Information about the lawyer representing the injured party, if applicable.
- 9. Insurance Information: Details about any insurance coverage related to the injury.
- 10. Signature and Date: The signature of the injured party and the date the form was signed.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or denial of your TRICARE claim. Ensure to complete and return the form promptly.
- Claim Delays: Your TRICARE claim may be delayed until the form is received.
- Claim Denial: Your TRICARE claim may be denied if the form is not submitted within the specified timeframe.
How do I know when to use this form?
- 1. Accident-Related Injuries: When you have been injured in an accident involving another party.
- 2. Workplace Injuries: When you have been injured on the job and third-party liability exists.
- 3. Medical Malpractice: When you have been injured due to medical malpractice.
- 4. Product Malfunctions: When you have been injured due to a malfunctioning product.
- 5. Assault-Related Injuries: When you have been injured in an assault and the assailant is liable.
Frequently Asked Question
How do I fill out this form?
Provide the required information about the injury, including details of the incident, parties involved, and medical care received. Complete all sections accurately and consult a legal advisor if needed.
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Upload the PDF and use PrintFriendly's digital signature tool to add your signature. Save and download the signed document.
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What information do I need to provide in this form?
You need to provide details about the injury, including the date, location, cause, parties involved, and medical care received. Also, include any legal or insurance information if applicable.
How do I submit this form after completing it?
Follow the submission instructions provided in the form, which may include returning it to the TRICARE processor or claims office.
What happens if I don't submit this form?
Failure to submit the form may result in delays or denial of your TRICARE claim.
Can I get help with filling out this form?
Yes, you can contact a Judge Advocate office or call the toll-free number provided in the form for assistance.
Is the form submission deadline strict?
Yes, you must submit the form within 35 days from the date of the letter to avoid claim denial.
Can a legal representative fill out the form for me?
Yes, a legal representative can assist you in completing and submitting the form.
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