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Fill Your Texas Clm 2 Form

The Texas CLM 2 form is a crucial document designed for filing claims related to student accidents that occur during school activities. This form ensures that parents and guardians can report injuries accurately and efficiently, facilitating access to necessary medical coverage. To get started on your claim, please fill out the form by clicking the button below.

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Article Guide

Dos and Don'ts

When filling out the Texas Clm 2 form, there are important dos and don’ts to keep in mind. These guidelines will help ensure that your claim is processed smoothly and efficiently.

  • Do complete Section 1 by a school official for school-related accidents.
  • Do ensure that all information is accurate and complete to avoid delays.
  • Do submit the claim form within 90 days from the date of injury.
  • Do keep a copy of the claim form for your records.
  • Don’t rely on the medical provider to submit the claim form for you.
  • Don’t forget to include itemized bills when submitting your claim.

Sample - Texas Clm 2 Form

STUDENT ACCIDENT CLAIM FORM

SUBMIT CLAIM FORM TO: Fidelity Security Life Insurance Company c/o Universal Fidelity Life Insurance Company P.O. Box 304

Duncan, OK 73534-0304 (800) 366-8354

Section 1 - Notice of Injury

(To be completed by School Official)

 

 

(This section may be completed by parent if 24-Hour coverage was purchased and accident is not school-related)

Name of School District:

 

 

 

 

Name of School:

 

School Phone No:

 

Name of Injured Student:

□ Male

□ Female

Grade:

Date of Injury:

Time of Injury:

□ AM

□ PM

Part of Body Injured:

 

□ Right Side

□ Left Side

Under whose supervision?

Was accident witnessed?

□ Yes

□ No

If "Yes", by whom?

The accident happened while the student was participating in:

□ Interscholastic UIL Activity

 

□ Non Interscholastic UIL Activity

Specify Sport/Activity:

Explain in detail how and where the injury occurred: ___________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Signature of School Official: ________________________________________________________________________________________________

 

 

(Title)

(Date)

IMPORTANT INFORMATION ON REVERSE SIDE

 

Section 2 - Parent/Guardian Statement (To be completed by Parent/Guardian)

 

Name of Student:

Date of Birth:

Home Phone No:

 

Is student covered by any insurance plan? □ Yes □ No

If yes,

Policy No.

 

Parent/Guardian Name:

 

Relationship to Student:

 

Address: _________________________________________________________________________________________________________________

(Street)

(City)

(State)

(Zip)

Father's Name:

Father's Employer:

 

 

Name of Father's Insurance Company (must be completed - If Father has no insurance - write "None"):

Insurance Company:

Policy No.

Mother's Name:

Mother's Employer:

Name of Mother's Insurance Company (must be completed - If Mother has no insurance - write "None"):

Name of Insurance Company:

Policy No.

I hereby authorize any insurance company, their authorized agent, hospital, physician, employer, school official or other person who has attended or examined the claimant to disclose when requested to do so all information with respect to any injury, policy coverage, medical history, consultations, prescription or treatment, and copies of all hospital or medical records, and itemized bills. A photo static copy of this authorization shall be considered as effective and valid as the original. I swear that the above information is true and correct to the best of my knowledge. I further understand that any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

__________________

_____________________________________________

______________________________________________________

(Date)

(Print Name of Student)

(Signature of Parent/Guardian)

Form CLM-2 (10)

 

 

ATTENTION PARENTS

Dear Parents,

Below are instructions for filing the Claim Form. Should you have any questions, contact the school trainer or call the number listed below. The school is NOT responsible for medical payment for your child. The school may have purchased a supplemental Accident Only Policy which may cover charges in excess of your own insurance policy. If you have no other insurance for your child, this policy may pay first or primary. This is a limited benefit policy and may not cover all medical bills for your child. Any charges not covered are YOUR RESPONSIBILITY.

For all school-related accidents, be sure to contact the school trainer or administrator.

INSTRUCTIONS FOR FILING THE CLAIM FORM

Section 1 must be completed by a school official for all school-related accidents and by the parent / guardian if 24-Hour coverage was purchased and the accident is not school-related.

Section 2 must be completed by the parent / guardian.

How to File A Claim

Step 1 - Complete and submit the claim form to the Claims Office at the address indicated below or send electronically to SAclaims@uflic.com. The claim form must be submitted within 90 days from the date of injury regardless of whether you have other insurance or not. Keep a copy of the claim form for your records and present a copy of the claim form to the provider or facility. DO NOT RELY on the provider or facility to submit the claim form.

Submit copies of itemized bills to the address indicated below. Itemized bills are original bills you receive, not monthly statements. Itemized bills are often called UB92 or HCFA1500 forms that provide the procedure code, diagnosis code, and the Providers’ address and Tax ID Number.

Step 2 - File a claim with your primary insurance first. insurance is your family and/or group insurance coverage.

Submit copies of all bills to your primary insurance first. Your primary The school’s policy is supplemental to all other valid coverage.

Step 3. After receiving payment or copies of Explanation of Benefits (EOB) from your family and/or group insurance, submit a copy of this claim form along with copies of your itemized bills and EOBs from your primary insurance company to the address below:

Fidelity Security Life Insurance Company c/o Universal Fidelity Life Insurance Company

P.O. Box 304

Duncan, OK 73534-0304

(800) 366-8354

Texas Kids First has unique access to one of the most creative innovations in the insurance industry – the Texas Kids First Provider Network (TKF Network)* – the first “no balance bill” non-profit network of providers in the State. The network consists of medical professionals and hospitals that have agreed to treat injured students from our insured districts for the services paid and outlined in the Schedule of Benefits of the Texas Kids First Student Accident Plans when the student patient has no other insurance.

Please refer to the website www.texaskidsfirst.com or call 1-800-366-8354 for a list of contracted providers in your area and to verify full assignment acceptance.

*The TKF Network is made available by Texas Kids First and is not affiliated with Fidelity Security Life Insurance Company.

FRAUDULENT CLAIM DISCLOSURE

Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Form CLM-2 (10)

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Documents used along the form

When filing a claim using the Texas Clm 2 form, several other documents may be required to support the claim process. Each of these forms serves a specific purpose and helps ensure that all necessary information is collected efficiently. Below is a list of commonly used documents alongside the Texas Clm 2 form.

  • Itemized Bills: These are detailed statements from healthcare providers that outline the services rendered, including procedure codes, diagnosis codes, and the provider's information. They are crucial for processing claims and must be submitted along with the claim form.
  • Explanation of Benefits (EOB): This document is provided by your primary insurance company after a claim has been processed. It explains what was covered, the amount paid, and any remaining balance that may need to be addressed. Submitting an EOB helps clarify the financial responsibilities of all parties involved.
  • Primary Insurance Claim Form: This form is used to file a claim with your primary insurance provider. It collects information about the injury and the medical treatment received, and it must be submitted before any secondary claims, including those to the school’s insurance policy.
  • Authorization for Release of Information: This document allows healthcare providers to share medical information with the insurance company. It is essential for verifying coverage and processing claims, as it ensures that all relevant medical records can be accessed.
  • School Incident Report: Often completed by school officials, this report details the circumstances surrounding the injury. It includes information such as the time, place, and nature of the incident, which can be helpful in substantiating the claim.
  • Parent/Guardian Statement: This statement, filled out by the parent or guardian, provides personal details about the injured student and any existing insurance coverage. It is vital for ensuring that all information regarding the claimant is accurate and complete.

Having these documents ready can streamline the claims process and help ensure that all necessary information is submitted. Each piece plays a role in providing clarity and support for the claim, making it easier for all parties to understand their responsibilities and rights. Always keep copies of everything submitted for your records.

Common mistakes

Filling out the Texas Clm 2 form can be straightforward, but several common mistakes can lead to delays or complications in processing claims. One significant error occurs when individuals fail to complete Section 1 accurately. This section must be filled out by a school official for school-related accidents. If a parent fills it out when it should be completed by a school representative, it may result in the claim being rejected. Ensuring that the correct person completes this section is crucial for a smooth claims process.

Another frequent mistake is neglecting to provide all required information in Section 2, which is designated for the parent or guardian. This section requires details such as the student's date of birth, insurance information, and contact details. Incomplete or missing information can delay the processing of the claim. It is essential to double-check that all fields are filled out completely and accurately before submission.

Many claimants also overlook the importance of submitting the claim form within the specified time frame. The Texas Clm 2 form must be submitted within 90 days from the date of the injury. Failure to meet this deadline can result in the denial of the claim. Keeping track of timelines and ensuring timely submission is vital for successful claims processing.

Lastly, individuals often misunderstand the need for itemized bills. Submitting a claim without the necessary itemized bills can lead to complications. Itemized bills should include specific details such as procedure codes and diagnosis codes. These documents are different from monthly statements and must be original bills. Ensuring that all required documentation accompanies the claim form is essential for a complete submission.

Misconceptions

Understanding the Texas Clm 2 form is essential for parents and guardians navigating the claims process for student injuries. However, several misconceptions often arise regarding this form. Here are eight common misunderstandings:

  • Only school officials can fill out the form. While Section 1 is typically completed by a school official for school-related accidents, parents can fill it out if 24-Hour coverage was purchased and the injury is not related to school activities.
  • The school is responsible for all medical costs. This is not accurate. The school may have a supplemental policy, but parents are ultimately responsible for any costs not covered by insurance.
  • Claims must be submitted immediately after an injury. Although timely submission is important, the claim form must be submitted within 90 days from the date of injury, allowing some time for completion.
  • All medical expenses will be covered by the insurance. The Texas Kids First policy is a limited benefit policy. It may not cover all medical expenses, and any uncovered charges are the parent's responsibility.
  • Submitting the claim form is the only step needed. Parents must also file a claim with their primary insurance first and submit the Explanation of Benefits (EOB) along with the claim form to the Texas Kids First policy.
  • Parents do not need to keep a copy of the claim form. It is advisable to keep a copy of the claim form for personal records and to present to medical providers, as they may not submit the claim on behalf of the parent.
  • All medical providers accept the Texas Kids First policy. Not all providers are part of the Texas Kids First Provider Network. Parents should verify provider participation before seeking treatment.
  • Fraudulent claims are not taken seriously. The form explicitly states that presenting a false claim is a crime, with potential legal consequences, highlighting the importance of honesty in the claims process.

By addressing these misconceptions, parents can better navigate the claims process and ensure they understand their responsibilities and the coverage provided by the Texas Clm 2 form.

Free Texas Clm 2 File

Key takeaways

Key Takeaways for Using the Texas CLM 2 Form:

  1. The Texas CLM 2 form is primarily used to report student accidents and must be submitted to Fidelity Security Life Insurance Company.
  2. Section 1 of the form is to be completed by a school official for school-related injuries, or by a parent if 24-hour coverage was purchased and the injury occurred outside school activities.
  3. Accurate details about the injury, including the time, date, and circumstances, are essential for processing the claim effectively.
  4. Section 2 requires information from the parent or guardian, including insurance details and authorization to disclose medical information.
  5. Claims must be submitted within 90 days of the injury, regardless of existing insurance coverage.
  6. It is important to keep a copy of the completed claim form for personal records and to provide a copy to the medical provider.
  7. Parents should file a claim with their primary insurance before submitting the Texas CLM 2 form, as the school’s policy is supplemental.
  8. Itemized bills should accompany the claim submission; these are original bills that detail the services provided, not monthly statements.
  9. Fraudulent claims can result in serious legal consequences, including fines and imprisonment, emphasizing the need for honesty in reporting.

File Characteristics

Fact Name Description
Form Title The official name of the form is the "Student Accident Claim Form." This form is used to report injuries sustained by students.
Submitting Entity Claims must be submitted to Fidelity Security Life Insurance Company, specifically to the address provided on the form.
Governing Law This form is governed by Texas law, particularly regulations regarding student insurance and accident claims.
Section Breakdown The form consists of two main sections: Section 1 is for school officials, and Section 2 is for parents or guardians.
Filing Deadline Claims must be submitted within 90 days from the date of injury, regardless of other insurance coverage.
Insurance Information Parents must disclose any existing insurance coverage for the injured student on the form.
Fraud Warning The form includes a warning that presenting false claims is a crime, which may lead to fines or imprisonment.
Provider Network The Texas Kids First Provider Network offers a unique "no balance bill" service for students with no other insurance coverage.

How to Use Texas Clm 2

Filling out the Texas Clm 2 form is essential for claiming benefits related to a student’s injury. This process involves providing detailed information about the incident and the injured student. Follow the steps below to ensure that the form is completed accurately and submitted on time.

  1. Obtain the Texas Clm 2 form. You can get it from the school or download it from the appropriate website.
  2. Complete Section 1, which is for the school official. Include the name of the school district, school name, school phone number, name of the injured student, gender, grade, date and time of the injury, part of the body injured, supervision details, whether the accident was witnessed, and a detailed explanation of how and where the injury occurred. Sign and date this section.
  3. If the injury is not school-related and 24-hour coverage was purchased, a parent or guardian can fill out Section 1 instead.
  4. Complete Section 2, which is for the parent or guardian. Provide the name of the student, date of birth, home phone number, and insurance coverage details. Include the parent or guardian's name, relationship to the student, and address. Fill in the father’s and mother’s names, employers, and insurance company details. Sign and date this section, confirming the information is true and correct.
  5. Make a copy of the completed claim form for your records. Present a copy to the medical provider or facility.
  6. Submit the claim form to the Claims Office at Fidelity Security Life Insurance Company, P.O. Box 304, Duncan, OK 73534-0304, or send it electronically to SAclaims@uflic.com. Ensure it is submitted within 90 days from the date of injury.
  7. File a claim with your primary insurance first. Submit copies of all bills to your primary insurance company.
  8. After receiving payment or an Explanation of Benefits (EOB) from your primary insurance, submit a copy of the claim form along with the itemized bills and EOBs to the Claims Office.

Following these steps will help you navigate the claims process smoothly. Make sure to keep all records and documentation organized for your reference.