Thank you for choosing our online questionnaire
Please provide the following information as shown on your paper questionnaire
- 1. Start
- 2. Injury / Illness Questionnaire
- 3. Incident Details
- 4. Signature Verification
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Start
* indicates a required field.
Espanol https://www.meridianresource.com/meridian/meridianquestionnaire
Injury / Illness Questionnaire
* indicates a required field.
*What was the reason for your treatment on the service date listed on your questionnaire?
(Please choose the option that best applies.)
Injury / Illness details
Before you proceed, you may want to have any auto insurance, workers’ compensation insurance or other liability insurance information and your claim number(s) available that are related to your injury.Espanol https://www.meridianresource.com/meridian/meridianquestionnaire
Incident Details
* indicates a required field.
Workers' Compensation Claim
Employer Details
*Please enter a valid Phone Number
Worker's Compensation Insurance Details
*Please enter a valid Phone Number
Motor Vehicle Accident Details
Responsible Person’s insurance details
*Please enter a valid Phone Number
Insurance Information for Vehicle the Patient was in
*Please enter a valid Phone Number
Injured Family Members
Click here to add other family members injured in this accident that are covered under your health plan.Other Accident Type - Injury Details
If product liability, please provide the name of the product
If Other, please describe the type of accident
*Please enter a valid Phone Number
If you are not making a claim or taking legal action because of this Injury / Illness please continue to the next step.
Espanol https://www.meridianresource.com/meridian/meridianquestionnaire
Signature & Verification
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Contact Information and Confirmation email
What is the best number to reach you if we need to contact you?*Please enter a valid Phone Number
*Please complete all required fields and try again.
Thank You! Your subrogation questionnaire information has been successfully submitted to Meridian Resource Company.
