Workers' Compensation Interview Form (1) Page 2

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Workers' Compensation Interview Form — Page 2
3.
______________________________________________________________________________________________
TREATMENT FROM:
TO:
WAS TREATMENT AUTHORIZED?
YES (
)
NO (
)
4.
______________________________________________________________________________________________
TREATMENT FROM:
TO:
WAS TREATMENT AUTHORIZED?
YES (
)
NO (
)
PRIOR ACCIDENTS AND/OR PAST HISTORY: ______________________________________________________
____________________
_____________________________________________________________________________________________
LANGUAGE:
INTERPRETER NEEDED:
YES (
) NO (
)
WORKERS’ COMPENSATION INSURANCE COMPANY:
_____________________
CLAIM NO: _______________________________ ADJUSTER:
WHAT IS THE BEST TIME TO CALL: __________________
TELEPHONE # _____________________________________
COMMENTS:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________

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