Subrogation Form

Section 1: Patient injury information

   Was the patient treated for injuries related to:
  • Auto accident
  • Motorcycle accident
  • Fall
  • Injury at home
  • Injury at work
  • Personal injury

Section 2: Accident and claim information

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)

Section 4: Your attorney information

Did you hire an attorney?

Section 5: Your information