Subrogation case referral

Thank you for using our online case referral form.

Here you can refer cases related to auto accidents, workers' compensation, slip-and-fall incidents, product liability, medical malpractice, or other third-party liability situations. So that we can handle your case referral most efficiently, please complete as much information as possible.

Other ways to refer a case:

If you prefer not to send your information online or are having trouble doing so please:

Fax your case referral information to us at 844-634-2520.
Mail your case referral information to us at:
Carelon Subrogation
PO Box 659940
San Antonio, TX 78265-9939

Please provide the following information.

Your Information

* indicates a required field.

* Name

* Email Address

* Company

Phone Number

Insurance Membership

Group Name

Group Number

* Group Type

Subscriber and Patient Information

Subscriber

* First Name

* Last Name

* Street Address

* City

* State

Zip

* Date Of Birth (mm/dd/yyyy)

* Subscriber ID Number / SSN

Phone Number

Patient information Same as subscriber

* First Name

* Last Name

* Date Of Birth (mm/dd/yyyy)

Phone Number

* Street Address

* City

* State

Zip

Injury / Illness Information

* Date of injury / illness (mm/dd/yyyy)

*Date of Service (mm/dd/yyyy)

* Injury / Illness Type

Injury / Illness Description Number of characters left: 256

Related Injury / Illness Number of characters left: 256

Responsible Party or Employer

Responsible Party

Insured By

Street Address

City

State

Zip

Phone Number

Patient's Attorney

Attorney's First Name

Attorney's Last Name

Firm Name

Street Address

City

State

Zip

Phone Number

Additional Information

Enter any additional information you feel we should know or consider. Number of characters left: 256

Source of Information

* Data Source

DCN

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Medical Benefits Management

Specialty Care Tools

Tools for Home Health, DMEPOS,
PAC-IM, SDoH and Wound Care providers

Subrogation case referral

Thank you for using our online case referral form.

Medical Benefits Management

Specialty Care Tools

Tools for Home Health, DMEPOS, PAC-IM, SDoH and Wound Care providers

Subrogation case referral

Thank you for using our online case referral form.

Tools for Home Health, DMEPOS,
PAC-IM, SDoH and Wound Care providers