Workers' Compensation Information Form

ADVERTISEMENT

ORTHOPAEDIC ASSOCIATES OF ROCHESTER, P.C.
WORKERS’ COMPENSATION INFORMATION FORM
Patient Name: Last ___________________________ First _________________ MI ____
Address_____________________________________ Home phone ___________________
City, State, Zip _____________________________ Cell phone _____________________
Patient Date of Birth __________________ Social Security # ______________________
Date of Injury: ________________________ Date reported to employer_____________
Workers Comp Board Number:______________________________________________
Carrier Case Number: ______________________________________________________
Employer:____________________________________________ Phone _________________
Employer address __________________________________________________________
__________________________________________________________
Employer’s Insurance Company ______________________________________________
Employer’s Ins.Co. Address ___________________________________________________
__________________________________________________________
I, the undersigned, hereby authorize payment directly to Orthopaedic Associates of
Rochester, PC, for any benefits for medical expenses or other indemnity that I may be
entitled to. I hereby give permission to OAR,PC, to release information, if requested, to
my primary care physician, hospitals, insurance carrier or Workers Compensation
carrier for coordination of benefits.
I understand that I am financially responsible for charges not covered by this
assignment, and that my failure to provide the necessary information to OAR, PC,
within TEN days will make me personally responsible for charges related to this injury.
In the event that I fail to prosecute the claim for Workers’ Compensation for this
condition, or it is determined by the Workers’ Compensation Board that this condition
is not a result of a compensable Workers’ Compensation case, I hereby agree to pay
Orthopaedic Associates of Rochester, PC, 2410 Ridgeway Avenue, Rochester, NY 14626,
their usual and customary fees for services rendered to me in this case. Or, if
applicable, the claim will be sent to my primary insurance company for payment with
the proper notice of decision.
Date_____________ Patient Signature ____________________________________
If signed by other than claimant, print name, address, and relationship of signer:
PRINT name ________________________________________ relationship ____________________
Address of signer, if not patient _______________________________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go