Skip to content
Hilliard Law
Malinckrodt Survey
This field is hidden when viewing the form
CaseID
This field is hidden when viewing the form
Case Type
First Name
Last Name
PART SIX: MEDICAL LIENS
Section 6.A: Did any insurance company pay for medical treatment for the opioid-related injuries that gave rise to your PI Claim?
Select
Yes
No
Section 6.B: In the last 20 years, was the opioid user who is the subject of your claim eligible for coverage by any of the following, or did any of the following actually pay for his/her opioid-related health costs? Respond by writing “Yes” or “No” next to each insurance provider name, and provide the requested information as to each. If any insurance carrier who provided coverage to the opioid user is not identified, please fill in that carrier’s information at the bottom of the chart.
Medicare
Yes
No
Medicare Street Address
Medicare Phone Number
Medicare Policy Number (if any)
Medicare Policy Holder
Medicare Dates of Coverage
Medicaid
Yes
No
Medicaid Street Address
Medicaid Phone Number
Medicaid Policy number (if any)
Medicaid Policy Holder
Medicaid Dates of Coverage
Tricare
Yes
No
Tricare Street Address
Tricare Phone Number
Tricare Policy Number (if any)
Tricare Policy Holder
Tricare Dates of Coverage
VA
Yes
No
VA Street Address
VA Phone Number
VA Policy Number (if any)
VA Policy Holder
VA Dates of Coverage
Champus
Yes
No
Champus Street Address
Champus Phone Number
Champus Policy Number (if any)
Champus Policy Holder
Champus Dates of Coverage
Private Insurance 1
Yes
No
Private Insurance 1 Name
Private Insurance 1 Street Address
Private Insurance 1 Phone Number
Private Insurance 1 Policy Number (if any)
Private Insurance 1 Policy Holder
Private Insurance 1 Dates of Coverage
Private Insurance 2
Yes
No
Private Insurance 2 Name
Private Insurance 2 Street Address
Private Insurance 2 Phone Number
Private Insurance 2 Policy Number (if any)
Private Insurance 2 Policy Holder
Private Insurance 2 Dates of Coverage
