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Accident or Injury Form

If GEHA pays benefits for you or your dependent and you also receive (or are entitled to receive) reimbursement from another party, or from your own insurance (such as auto insurance), GEHA is required to recover its payments. This is called subrogation, or right of reimbursement, and is mandated by the Office of Personnel Management (OPM). Please refer to your Plan brochure under "When others are responsible for injuries" for a complete explanation.

If you have received a letter in regards to an accident or injury, please include the claim number on this form. The claim number can be found on the letter your received.

If you have submitted a claim for which another party is responsible, this form will help document your claim. Please complete the form to send by email to GEHA.

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Please enter the month, day and year of the patient's illness/injury.
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Was this injury work related?


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If an accident, were other dependents who are covered by GEHA injured in the accident?


Is someone else responsible for your or your dependent's injury?

Have you filed a claim with the responsible party's insurance company?


Was this a motor vehicle accident?


Have you filed a claim with your own auto carrier?


Have you obtained an attorney to represent yourself or your dependent?