Fillable CITY OF SPRINGFIELD, OHIO Personal Injury Claim Statement (City Of Springfield, Ohio)

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CITY OF SPRINGFIELD, OHIO Personal Injury Claim Statement (City Of Springfield, Ohio)

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The CITY OF SPRINGFIELD, OHIO Personal Injury Claim Statement (City Of Springfield, Ohio) form is 3 pages long and contains:

  • 2 signatures
  • 7 check-boxes
  • 30 other fields

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File type: PDF

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CITY OF SPRINGFIELD, OHIO
Personal Injury Claim Statement Form
NAME
BIRTH DATE
HOME PHONE
CELL PHONE
STREET ADDRESS
CITY
STATE
ZIPCODE
EMAIL ADDRESS
EMPLOYER NAME
DESCRIPTION OF INCIDENT
If you have photos of the damage that resulted, please attach them to this form.
INCIDENT DATE:
INCIDENT LOCATION:
CITY DEPARTMENT INVOLVED, IF ANY:
NAME OF CITY EMPLOYEE INVOLVED, IF ANY:
POLICE REPORT MADE?
YES:
☐
NO:
☐
If no, why?
DESCRIPTION: (Please be as specific as possible in your description. Include as much detail as possible, such as
who was with you, weather conditions, etc. If you require more space, please attach a separate sheet.)
AFFIDAVIT OF INSURANCE
If uninsured, please complete the following:
I, , swear or affirm that I do not have Health insurance. Alternatively, I
swear or affirm that I/my company is self-insured.
UNINSURED CLAIMANT SIGNATURE: ____________________________ DATE: __________
If insured, please complete the following:
HEALTH INSURANCE COMPANY:
HEALTH INSURANCE POLICY NUMBER:
Ohio Revised Code, Section 2744.05 outlines limitations of damages awarded for claims against political
subdivisions. If a claimant receives or is entitled to receive benefits from insurance policy or policies,
that amount will be deducted from any award the political subdivision may consider paying. This
includes Medicaid, Medicare and Health insurance policies.
**You MUST file a claim with your insurance company prior to filing a claim with the City of Springfield.
Documentation of filing of a claim with your insurance company must be attached to this Claim Packet.
You must also submit a copy of your Health insurance Summary Plan Description with this Claim
Packet.**
FURTHERMORE, WITH RESPECT TO ANY DAMAGES ALLEGED IN THIS CLAIM PACKET, CLAIMANT MUST
BE MADE AWARE THAT, BY STATUTE, THE CITY OF SPRINGFIELD, OHIO MAINTAINS SIGNIFICANT
IMMUNITY FROM LIABILITY FOR DAMAGES OF THIS NATURE. OHIO REVISED CODE SECTION 2744.05
ADDRESSES THESE IMMUNITIES. IN SHORT, CLAIMANT MUST PROVE THAT THE CITY OF SPRINGFIELD
WAS NEGLIGENT OR RECKLESS IN THEIR ACTIONS. IF THE CLAIMANT CANNOT PROVE, THROUGH THIS
CLAIM PACKET, NOR THE CITY CAN FIND RECORDS INDICATING NEGLIGENCE OR RECKLESS BEHAVIOUR,
THE CITY WILL MAINTAIN IMMUNITY AND WILL BE UNABLE TO PAY THE REQUESTED CLAIM.
I state that I am not entitled to receive any additional reimbursement for these damages from any
other source other than the City of Springfield, and that the claim(s) arising from these damages are
a direct result of this incident.
I, , attest that by signing below, I have read and understand
the requirements for submission of a claim to the City of Springfield. I further understand that I
MUST complete the Authorization for Release of Medical Records attached below and submit a
signed, notarized version of the document to the City of Springfield Law Department.
CLAIMANTS SIGNATURE: DATE: _________
Send completed form with supporting documentation to law@springfieldohio.gov
Completed Claim Form Photos of Damage Two Estimates Completed W9 Form
Insurance Summary Plan Description Documentation a Claim has been filed with Insurance
Signed and notarized Authorization for Release of Medical Records
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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
I, Insert Name Here. , hereby authorize the release of any and all medical information and all records from
physicians, psychiatrists, psychologists, counselors, social workers, therapists and any individuals providing health
care, as well as any hospitals, clinics, doctor’s offices, or health care providers including those listed below to the
City of Springfield, Law Director Jill N. Allen, and any Assistant Law Director, and/or their agents.
• Outpatient treatment records for physical and psychological, psychiatric, emotional illness, or drug
and/or alcohol abuse.
• Psychological or psychiatric evaluation(s), reports, assessments, treatment notes, summaries, or other
documents with diagnoses, prognoses, recommendations, or testing records, and behavioral observations or
checklists completed by any staff member or the patient, or similar documents.
• Treatment, recovery, rehabilitation, aftercare plans, and other similar plans.
• Social, family, educational, and vocational plans.
• Social work assessments and plans.
• Progress, nursing, case, or similar notes.
• Billing/Financial records.
• Information about how the patient’s condition(s) affects or has affected his/her ability to work and to
complete tasks or activities of daily living.
• Academic and educational records, including achievement and other tests’ results, reports of teachers’
observations, and all other school or special education documents.
• HIV related information and drug and alcohol information.
For the date(s) of care beginning _______________ to the present.
The information will be used only for purposes relating to a claim I have filed against the City of Springfield, Ohio.
The authorization for release shall expire upon final adjudication of the aforementioned action. Any and all records
shall be released to the City of Springfield, Law Director Jill N. Allen, and any Assistant Law Director, and/or their
agents, located at 76 N. High St., Springfield Ohio, 45506.
I have the right to revoke this authorization at any time provided that said revocation is in writing and delivered to
the City of Springfield, Law Director Jill N. Allen except to the extent that the City of Springfield has taken action in
reliance of said authorization.
I realize the potential for information disclosed pursuant to this authorization to be subject to disclosure by the
recipient and to no longer be protected by the Privacy Rule of the Health Insurance Portability and Accountability
Act.
A copy of this authorization is valid as the original.
SIGNATURE: ______________________________________________ DATE: __________
STATE OF OHIO )
COUNTY OF CLARK ) SS:
SWORN TO BEFORE ME and subscribed in my presence the day of _____, 20____.
___________________________________
NOTARY PUBLIC, STATE OF OHIO
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CITY OF SPRINGFIELD, OHIO Personal Injury Claim Statement (City Of Springfield, Ohio)

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Completed 16 July 2020

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