HEALTH INSURANCE RESPONSE FORM – ACCIDENT DETAILS
 

Thank you for selecting the ISO Health Insurance Plan. HealthSmart is the claim administrator of your plan. (“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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HealthSmart
3320 West Market Street Suite 100 | Fairlawn Ohio 44333 | 800-203-4720 (tel) 806.473.3136 (fax)