Form C-4 - Employee'S Claim For Compensation/report Of Initial Treatment - 2007
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1EMPLOYEE’S CLAIM FOR COMPENSATION/REPORT OF INITIAL TREATMENT
FORM C-4
PLEASE TYPE OR PRINT
EMPLOYEE’S CLAIM – PROVIDE ALL INFORMATION REQUESTED
First Name
M.I.
Last Name
Birthdate
Claim Number
Sex
(Insurer’s Use Only)
M
F
Home Address
Age
Height
Weight
Social Security Number
City
State
Zip
Telephone
Mailing Address
City
State
Zip
Primary Language Spoken
INSURER
THIRD-PARTY ADMINISTRATOR
Employee’s Occupation (Job Title) When Injury or Occupational
Disease Occurred
Employer’s Name/Company Name
Telephone
Office Mail Address (Number and Street)
Date of Injury
Hours Injury (if applicable)
Date Employer Notified
Last Day of Work After Injury
Supervisor to Whom Injury Reported
(if applicable)
or Occupational Disease
am
pm
Address or Location of Accident (if applicable)
What were you doing at the time of the accident? (if applicable)
How did this injury or occupational disease occur? (Be specific and answer in detail. Use additional sheet if necessary)
If you believe that you have an occupational disease, when did you first have knowledge of the disability and its
Witnesses to the Accident (if
relationship to your employment?
applicable)
Nature of Injury or Occupational Disease
Part(s) of Body Injured or Affected
I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE PROVIDED THIS INFORMATION IN ORDER TO OBTAIN THE BENEFITS OF NEVADA’S
INDUSTRIAL INSURANCE AND OCCUPATIONAL DISEASES ACTS (NRS 616A TO 616D, INCLUSIVE OR CHAPTER 617 OF NRS). I HEREBY AUTHORIZE ANY PHYSICIAN, CHIROPRACTOR,
SURGEON, PRACTITIONER, OR OTHER PERSON, ANY HOSPITAL, INCLUDING VETERANS ADMINISTRATION OR GOVERNMENTAL HOSPITAL, ANY MEDICAL SERVICE ORGANIZATION, ANY
INSURANCE COMPANY, OR OTHER INSTITUTION OR ORGANIZATION TO RELEASE TO EACH OTHER, ANY MEDICAL OR OTHER INFORMATION, INCLUDING BENEFITS PAID OR PAYABLE,
PERTINENT TO THIS INJURY OR DISEASE, EXCEPT INFORMATION RELATIVE TO DIAGNOSIS, TREATMENT AND/OR COUNSELING FOR AIDS, PSYCHOLOGICAL CONDITIONS, ALCOHOL OR
CONTROLLED SUBSTANCES, FOR WHICH I MUST GIVE SPECIFIC AUTHORIZATION. A PHOTOSTAT OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL.
Date
Place
Employee’s Signature
THIS REPORT MUST BE COMPLETED AND MAILED WITHIN 3 WORKING DAYS OF TREATMENT
Place
Name of Facility
Diagnosis and Description of Injury or Occupational Disease
Is there evidence that the injured employee was under the influence of alcohol
Date
and/or another controlled substance at the time of the accident?
No
Yes (if yes, please explain)
Hour
Have you advised the patient to remain off work five days or more?
Treatment:
Yes Indicate dates: from ____________ to __________________
No
If no, is the injured employee capable of:
full duty
modified duty
X-Ray Findings:
If modified duty, specify any limitations/restrictions: _______________________
From information given by the employee, together with medical evidence, can you directly
_________________________________________________________________
Yes
No
connect this injury or occupational disease as job incurred?
_________________________________________________________________
Is additional medical care by a physician indicated?
Yes
No
Do you know of any previous injury or disease contributing to this condition or occupational disease?
Yes
No
(Explain if yes)
Date
Print Doctor’s Name
I certify that the employer’s copy of
this form was mailed to the employer on:
Address
INSURER’S USE ONLY
City
State
Zip
Provider’s Tax I.D. Number
Telephone
Doctor’s Signature
Degree
ORIGINAL – TREATING PHYSICIAN OR CHIROPRACTOR
PAGE 2 – INSURER/TPA
PAGE 3 – EMPLOYER
PAGE 4 – EMPLOYEE
Form C-4 (rev.10/07)
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