Florida Tort Info Form
P.O. Box 12188
Tallahassee, FL 32317-2188
Toll Free: (877) 357-3268
Fax: (844) 845-8352
flsubro@gainwelltechnologies.com


Tort Information Form

Medicaid Recipient's Information
* Indicates required field.
*  * 
  (MM/DD/YYYY) 
 
Phone Number:  ( ) -
Home Phone:  Work Phone:  Cell Phone: 
Accident/Incident Information
  (MM/DD/YYYY) 
* Accident/Incident Type 
Select the type of incident that best describes why the patient received medical care. (In some cases, especially when work related, more than one may apply. Select additional as appropriate.)
  Illness
Work Related
Product
 Auto Accident
Home Owners
Medical Malpractice
 Slip and Fall
School
Other
  

Characters Left
* Please select Body part(s) injured (Chose all that apply.):
  Face/Head
Upper Arm
Upper Leg
 Neck/Throat
Elbow
Knee
 Shoulder
Lower Arm
Lower Leg
 Back
Hands
Foot
 Chest/Thorax
Hip
Other
  

Characters Left
Is the patient still being treated for this? 
  Yes No
  (MM/DD/YYYY) 
Liable Party's Information
Phone Number:  ( ) -
Are there any additional liable parties? 
  Yes No
Liable Party's Insurance Company Information
Phone Number:  ( ) -
Adjuster Telephone Number:  ( ) - Fax Number:  ( ) -
Liable Party's Attorney Information
Telephone Number:  ( ) - Fax Number:  ( ) -
Recipient's Insurance Company Information
Phone Number:  ( ) -
Adjuster Telephone Number:  ( ) - Fax Number:  ( ) -
Recipient's Attorney Information
Telephone Number:  ( ) - Fax Number:  ( ) -
Information of Person Submitting This Form
Telephone Number:  ( ) - Fax Number:  ( ) -

Please enter the information requested below:

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