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Arcadia Boosters Club
Injury Procedures and Claim Form

1.	Any injuries must be reported to the President of ABC.
2.	The policyholder (Recreation Organization) is to fill in the name of the Recreation Organization and complete Part I before giving the claim form to the Participant or Parent.
3.	The claim form must be signed and dated by a representative from the Recreation Organization.
4.	The Participant, Parent or Guardian is to complete Part II of the claim form in full. If the form is not completed in full, it may delay processing the claim.
5.	Completed claim form should be submitted within 90 days of the accident. Do not wait until medical bills are received.
6.	Medical Bill: Attach all medical bills. All submitted medical bills must be itemized for service (a balance due statement is not acceptable and may delay processing). A physician’s office should submit an invoice per HCFA 1500. A hospital and/or emergency room should submit an invoice per UB 92. HCFA 1500 and UB 92 are universal billing forms supplied by the physician’s office and/or hospital.
7.	Attach a copy of your completed claim form with all itemized medical bills and mail them to the address on the claim form.
8.	Retain one copy of all claims information for your records.

Notification of Injury Form