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Subrogation Form

Section 1: Patient injury information

Was the patient treated for injuries related to:

Section 2: Accident and claim information

State

Was anyone at fault?

Did you file a claim against the liable party?

Section 3: Responsible insurance company (if not Blue Cross Blue Shield of Michigan)

State

Section 4: Your attorney information

Did you hire an attorney?

State

Section 5: Your information

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