NOTICE OF PUPIL INJURY FORM
A nonprofit independent licensee of the BlueCross BlueShield Association / Mail completed form to:
Attention SAP Department
Excellus BlueCross BlueShield
P.O. Box 22999
Rochester, New York 14692
Section I – SCHOOL must complete and sign.
Make 5 copies of signed /dated form and distribute: 2 COPIES: Parent/Guardian COPY: School (File) COPY: Nurse COPY: School Health Svcs.
Student Name: (Last, First, Middle Initial) PLEASE PRINT / Student Birthdate: (mm/dd/yyyy)// / Sex:
Male Female
School District Name: Rochester City School District / School Identification Number/Program: 9101-1
Name of School: / Was injury a result of a motor vehicle accident?: Yes No
Date of Injury: // / Place of Accident:
Parent/Guardian Name: / Inside School Coming to School On School Grounds
Parent/Guardian Address: / Returning from School Other
Type of Injury (Specify body part): / Detailed description of how injury occurred:
Witness or School Authority Signature: / Date:
Section II – Parent/Guardian MUST sign, complete and date this form and SUBMIT to Excellus within 10 business days. PRINT CLEARLY.
Is child covered under another health or dental insurance plan? £ Yes £ No If yes, please complete the information below.Is child covered under: £ Child Health Plus £ Medicaid £ Not Applicable
Name of Insurance Carrier: / Policy/Identification Number:
Is child covered under Father/Guardian
£ Yes £ No
Full Name:
Relationship to pupil:
Address (if different from pupil):
/ Medical
Name of Insurance Carrier:
Insurance Carrier Phone Number:
Policy/Identification Number:
/ Dental
Name of Insurance Carrier:
Insurance Carrier Phone Number:
Policy/Identification Number:
Is child covered under Mother/Guardian
£ Yes £ No
Full Name:
Relationship to pupil:
Address (if different from pupil):
/ Medical
Name of Insurance Carrier:
Insurance Carrier Phone Number:
Policy/Identification Number:
/ Dental
Name of Insurance Carrier:
Insurance Carrier Phone Number:
Policy/Identification Number:
Claims
¡ In order to process claims under the School Accident Program (SAP) this form must be completed and on file with Excellus.
¡ For claims reimbursement, please submit this Notice of Pupil Injury Form and a SAP claim form (located in School Accident Program Guide) along with an itemized bill and Explanation of Benefits from the student’s medical plan (if applicable).
Due to a New York State mandated regulation, all claims related to an accidental injury to a sound and natural tooth should be submitted to the student’s medical plan first then to their dental plan (if applicable). Submit any remaining balances to SAP with an Explanation of Benefits from both medical and dental plans along with an itemized bill.
Notice: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
Parent/Guardian Signature Date
SAP (School Accident Program) Pupil Injury Form 07/20/09