FL Medicaid Casualty Recovery Program
P.O. Box 12188
Tallahassee, FL 32317-2188
Toll Free: (877) 357-3268
Fax: (844) 845-8352
flsubro@conduent.com


Tort Information Form
Medicaid Recipient's Information
* Indicates required field.
* First Name:  Middle Initial:  * Last Name: 
Date of Birth :    (MM/DD/YYYY) 
Medicaid Id Number:    Last Four Digits of Social Security Number (SSN): 
Address: 
City:  State:  Zip Code: 
Phone Number:  ( ) -
Home Phone:  Work Phone:  Cell Phone: 
Accident/Incident Information
Accident/Incident Date :    (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
  
Please describe the incident: 
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
  
If Other, please describe: 
Characters Left
Is the patient still being treated for this? 
  Yes No
If no, when did the treatment end? :    (MM/DD/YYYY) 
Liable Party's Information
First Name:  Last Name: 
OR Company Name: 
Address: 
City:  State:  Zip Code: 
Phone Number:  ( ) -
Are there any additional liable parties? 
  Yes No
Liable Party's Insurance Company Information
Insurance Company Name: 
Address: 
City:  State:  Zip Code: 
Phone Number:  ( ) -
Adjuster First Name:  Adjuster Last Name: 
Adjuster Telephone Number:  ( ) - Fax Number:  ( ) -
Policy #:  Claim #: 
Liable Party's Attorney Information
First Name:  Last Name: 
Firm Name: 
Address: 
City:  State:  Zip Code: 
Telephone Number:  ( ) - Fax Number:  ( ) -
Email Address: 
Recipient's Insurance Company Information
Insurance Company Name: 
Address: 
City:  State:  Zip Code: 
Phone Number:  ( ) -
Adjuster First Name:  Adjuster Last Name: 
Adjuster Telephone Number:  ( ) - Fax Number:  ( ) -
Policy #:  Claim #: 
Recipient's Attorney Information
First Name:  Last Name: 
Firm Name: 
Address: 
City:  State:  Zip Code: 
Telephone Number:  ( ) - Fax Number:  ( ) -
Email Address: 
Information of Person Submitting This Form
First Name:  Last Name: 
Firm Name: 
Telephone Number:  ( ) - Fax Number:  ( ) -
Email Address: 

Please enter the information requested below:

1ohnlp

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