Mmc4314 Workers Compensation Form
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1
2WORKERS COMPENSATION INSURANCE FORM
PATIENT INFORMATION
NAME: __________________________________
SS #: ______________________________
ADDRESS: ______________________________
BIRTHDATE: ________________________
________________________________________
PHONE #: __________________________
EMPLOYMENT INFORMATION
EMPLOYER: ______________________________
CONTACT: __________________________
ADDRESS: ______________________________
PHONE #: __________________________
________________________________________
DATE OF INJURY: ____________________
HOW DID INJURY OCCUR?____________________________________________________________
__________________________________________________________________________________
WORKERS COMPENSATION INSURANCE CO. INFORMATION
INSURANCE CO. NAME: ____________________
CONTACT: __________________________
ADDRESS: ______________________________
PHONE #: __________________________
________________________________________
CC #: ______________________________
LEGAL REPRESENTATIVE:__________________
WCB #: ____________________________
PHONE #: ________________________________
__________________________________
AUTHORIZATION
I hereby authorize MMC Orthopaedics to release information obtained during the course of any
examination and treatment to my authorized worker’s compensation insurance carrier for the above-
described injury. I hereby assign payment directly to MMC Orthopaedics for any medical services
rendered. I understand that I am responsible for payments for all services rendered and any associated
costs for collection should such action become necessary if worker’s compensation coverage were denied
for any reason. I agree that this authorization shall be valid until rescinded in writing or replaced by one of
a later date. A photocopy of this assignment shall be considered as valid as the original. I have read the
_
above and fully understand the terms thereof:
_______________________________________ _______________________________________ ______________________
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I hereby authorize MMC Orthopaedics to release information to anyone requestion information in regard
to my worker’s compensation claim over the telephone and identifying themselves as a representative of
my worker’s compensation carrier.
_______________________________________ _______________________________________ ______________________
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I certify that the information given by me in regard to worker’s compensation is correct. To the best of my
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knowledge, the claim is active at the time of signature. I also understand that I may be responsible for
payment of coverage not covered by the worker’s compensation program.
I hereby give my permission for my charges to be submitted to by private medical insurance carrier if the
worker’s compensation claim is denied or found to be invalid.
MMC4314 (2/13)
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