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Program |
Manual Section |
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All Programs |
Staff must document information about any third party liability (TPL), and complete an Accident/Injury Referral as needed. Use the following steps to report possible third-party liability due to an accident or injury using the HMS web site:
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Step |
Action |
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1 |
Go to HMS online reporting. NOTE This site may not support Internet Explorer. |
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2 |
Enter information available to you. (see the table below for instructions). NOTE You do not need to enter all of the information on the screen. Just enter what you have and can get from the customer. |
Follow the instructions below to complete the online form:
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Section |
Action |
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Recipient/Member (Injured Party) Information |
Enter the customer’s information. |
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Accident/Incident and Injury Information |
Enter any information you have about the accident or injury. |
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Liable Person(s) Involved Information |
Enter available information about anyone who may be legally responsible (liable) for the accident or injury. |
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Liable Insurance Company Information |
Enter the best available information. |
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Plaintiff Attorney Information |
Enter information about the customer’s attorney when known. |
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Defense Attorney Information |
Enter information about the liable person’s or liable insurance company’s attorney when known. |
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Information of Person Submitting This Form |
AHCCCS Staff: Enter “Arizona State AHCCCS” in the “Company/Organization Name” field. DES Staff: Enter “Arizona State DES” in the “Company/Organization Name” field. |