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Third Party Liability (TPL) Form
  

The following are instructions of how to correctly fill out TPL form.
Click here to download the TPL form.. Once the form has been printed and correctly filled out, please mail to:

Attention: TPL Unit
Electronic Data Systems
P.O. Box 2006
Warwick, RI 02887-9901

FIELD	Instruction
Field 1 - Patient's Name	Enter the Patient's name
Field 2 - Medicaid ID Number	Enter the Recipient's Medicaid ID number
Field 3 - Insurance Name / Medicare	Indicate the name of the Insurance Company or Medicare
Field 4 - Policy Number	Indicate the Policy Number, if available
Field 5- Effective Date	Enter the Policy effective date, if available
Field 6- End Date	Enter the Policy End Date, if available
Field 7 - Policy Holder Name	Indicate the name of the Policy Holder
Field 8 - Relationship to insured	Check the appropriate box to indicate the relationship to the insured
Field 9 - "Does this information appear on the patient's current  Med. Asst. Card?" __Yes ___No	Check off the appropriate box to indicate if the information is or is not currently reflected on the Patient's Medical Assistance ID Card
Field 10 - If Yes, explain the nature of the problem	If applicable, enter a brief explanation of the current problem. Example: "Coverage indicated on the Medical Asst. Card has now elapsed."
Field 11 - Provider Name	Enter the Provider's Name
Field 12 - Provider Medicaid ID Number	Enter the Provider's Medicaid ID Number
Field 13 - Contact Person	Indicate a Contact Person
Field 14 - Telephone Number	Indicate the telephone number of the Contact Person