Accident Information Questionnaire Optum
Optum Accident Information Questionnaire
Subrogation / Right of Reimbursement

Welcome. We are investigating to determine if any other party or insurance carrier may have responsibility to pay for the medical treatment noted on the letter directing you to this website. The information we are requesting relates only to the incident referred to in that letter.

We respect your right to privacy and will handle the information you submit with utmost discretion.

Please enter the information displayed on the letter that you received

(* denotes a required field)

Case # *
Patient Last Name *
Patient Zip Code *
To speak with a representative, please call the toll free number on your letter, weekdays 7a.m. to 7 p.m. CST.