HEALTH INSURANCE RESPONSE FORM – ACCIDENT DETAILS
 
Thank you for selecting The Ohio State Student Health Insurance Benefits Plan. HealthSmart Benefit Solutions partners with the plan to process member claims. (“Claims” are formal requests for the plan to pay for services you’ve utilized, usually submitted by the providers you see.) We have received an accident claim and need additional information from you in order to complete our processing of your claim.
 
 
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6. Did this injury happen while participating in one of the following? (select one): *
7. Was the injury the result of a motor vehicle accident? *
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PO Box 94468| Lubbock, TX  79493-4468 | 844.206.0374 (tel) 806.473.3136 (fax)