Personal Injury Questionnaire
Frequently Asked Questions
Who is this letter for?
The letter is specifically for the person listed on the front of the letter. If that person is a minor, the parent or guardian will need to complete the questionnaire through the website and note their contact information at the end of the questions. If the person who received the services is unable to complete the form, someone other than the recipient (for example, nurse, friend, or a family member) may complete it for them through the website.
Why did I receive this letter?
State Medicaid programs and their contractors are required by federal law to research medical claims billed for certain medical services. The medical services provided to you were billed under one of these diagnosis codes. Your State Medicaid program would like to know if these medical services were provided because of an accident or injury that was the fault of some other person, or if an insurance company would be responsible for the payment of these medical claims.
What does this letter mean?
The letter includes a basic questionnaire that needs to be completed through the website to obtain additional information about the treatment you received on or around the date(s) of service indicated in the letter.
Why do I have to fill this out? How is it going to affect me?
Federal law requires that the State Medicaid Agency pursue all possible sources that are available to pay for the medical services. Because you received Medicaid benefits, you must comply with this request for information and complete the questionnaire. This requirement is also stated on the letter you received.
I wasn't in an accident. What do I do with this letter now?
If you were not in an accident or had no injury that was accident related, please complete that information through the website.
The services I received were a result of my disability or long term care and that is why I am on Medicaid. Do I still have to complete the questionnaire?
Yes, if you received the services as a result of a disability or long term care, please complete that information through the website.