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If there is a balance due after primary insruance consideration please submit the itemized medical bill HCFA1500 from physician or UB04 from hospital and the corresponding Explanation of Benfits EOB. COM FAX 801-415-9648 MAIL 1905 WEST 4700 SOUTH 212 SALT LAKE CITY UT 84129 WFTDA will verify coverage and submit a copy of the First Report of Accident to American Specialty Insurance Risk Services Inc. 2. All First Reports of Accident must be approved by WFTDA for consideration of claims. EMAIL...
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How to fill out wftda injury report form

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How to fill out wftda injury report

01
First, gather all necessary information such as the injured skater's name, team, and contact information.
02
Next, describe the injury in detail, including the date, time, and location it occurred.
03
Include any relevant witnesses or parties involved in the incident.
04
Specify the circumstances surrounding the injury, such as a particular game or practice.
05
Document any medical treatment received by the skater, including healthcare providers and facilities.
06
Provide a summary of the impact the injury may have on the skater's ability to participate in future events.
07
Submit the completed injury report to the appropriate WFTDA representative or committee.

Who needs wftda injury report?

01
Anyone involved in roller derby, including skaters, coaches, officials, and league organizers, may need to complete a WFTDA injury report.
02
It is primarily used for reporting and tracking injuries within the roller derby community to ensure player safety and help with data analysis.
03
WFTDA member leagues, independent teams, and individual skaters all benefit from submitting injury reports as it contributes to safer practices and game play.
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WFTDA injury report is a document used to track and record injuries that occur during roller derby activities.
All member leagues of the WFTDA are required to file injury reports.
WFTDA injury report can be filled out online through the WFTDA member portal.
The purpose of the wftda injury report is to monitor and analyze injuries in roller derby in order to improve safety measures.
The information that must be reported on the wftda injury report includes details of the injury, the player involved, the circumstances of the injury, and the outcome.
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