Member Third Party Liability Information

If you received a request from either CNIC or UMR for Third Party Liability Information please complete the form below. By completing this form a determination can be made as to whether CEBT or some other entity is the primary payor responsible for claims that have been submitted.

Member Name: First, Last:
Email:
Member ID:
Patient Name:
Services Provided By:
Date of Service:
Total Charge Amount:
Was Claim Due to Injury?

Yes

No
Injury/Illness Description:
First Date of Treatment:
Date of Injury:
How Did The Injury Happen:
Place of Injury:
Was Injury at Work:
Do You Expect Further Treatment:
Is This Causing Aggravation at Work:
Has Employer Been Notified:
Is Injury From Motor Vehicle Accident:
Was Vehicle Covered By Insurance:
Other Party Name:
Other Party Address:
Other Party Phone:
Claim Number:
Policy Number:
Was Accident Reported to Law Enforcement:
Name of Agency:
Agency Address:
Has Attorney Been Retained:
Home Phone:
Work Phone:
Electronic Signature:

Member Third Party Liability Form

Member Third Party Liability Information