FLORIDA YOUTH SOCCER ASSOCIATION

CLAIM PROCEDURE

WHEN A CHILD IS INJURED

OBTAIN APPROPRIATE MEDICAL ATTENTION

The TSC Vice President has claim forms and information. The claim form can be downloaded as a PDF File

DISTRICT COMMISSIONER AND COACH:

· Verifies the player by filling in the player's name and registration number on the case report (claim form). The district commissioner then signs the claim form .
· Sends to parent for completion of part I (the front of the form).
· Completes injury log detail.

PARENT:

Fully completes part I and part II, and signs part II. (Back of the form).

THE FORM IS MAILED TO:

M.E. WILSON COMPANY, INC.,
FYSA Claims Dept
P.O. Box 373
Tampa, FL 33601

WITH ANY BILLS AND EXPLANATION OF BENEFITS FROM PRIMARY INSURANCE. (Bills must show patient's name, condition/diagnosis, treatment given, payments and denials)

M.E. WILSON COMPANY:

Consolidates claim form and bills, and expedites to the insurance company for payment. The insurance company processes claim and mails check (takes approximately 5-7 weeks).