Workers Compensation / Ime Information
ADVERTISEMENT
1WORKERS COMPENSATION / IME INFORMATION
Chart#_______________ Appt Date/Time: ____________________Office ________
MD__________
Patient Name
________________
____
________________________________________
Patient Address
_________________________________________________________________
Home Phone:
________________
Date of Birth:
_________________ SSN# ____________________
Email Address:
_______________________________ Translator Needed?
Yes
No
Employer
________________________________________________________________
Employer Address:
________________________________________________________________
________________________________________________________________
Employer Phone #:
________________________________________________________________
W/C Carrier
_______________________
What Network?
_______________________________
W/C Address
_______________________________________________________________________
W/C Phone #
_________________________
Fax# _________________________________
Adjusters Name:
____________________________________________________________________
Adjuster Telephone #
__________________________ Ext. _______
Adj/NCM Email
Date of Accident:
______/______/______
Claim Number_______________________________
Type of Injury
________________________________________________________________
Nurse Case Managers Name:
____________________________________________________________
Phone #__________________________________
Fax #_______________________________________
Is Patient Represented by An Attorney?
_____Yes
____
No
If yes, who?
_________________________
PT______ MRI_____ # OF DR=S_______ SX________ OLD INJURY _______ INJECTIONS_______ X-RAYS ______
MEDICAL RECORDS
______
Evaluation only
Evaluation and treatment
Second Opinion
CPT CODE: ___________, ___________, ___________
TOTAL
AMOUNT OF VISIT $___________
INITIALS________DATE____________
Updated:
20 January 2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal