Aim Works Med Fax Form Aim Mutual Insurance Companies
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2MEDICAL ONLY / MED FAX REPORT
DO NOT File This Form With
Fax this report to A.I.M. Mutual Ins. Cos. at 781-270-5599
The Dept. of Industrial Accidents
Tel. No. 1-800-876-2765
MedFax Rev. 3/11
Employee Name (Last, First, MI):
Employee Telephone:
Social Security Number:
S
(
)
-
--
--
E
Employee Address:
Sex:
Date of Birth:
C
(
) F (
) M
/
/
T
Location Code:
Insurer:
A.I.M. Mutual
MEIC
AEIC
Marital Status:
I
NH Employers
(
) Single (
) Married
PO Box 4070, Burlington, MA 01803-0970
O
Employer:
Employer Telephone:
Policy Number:
N
(
)
-
Employee Occupation:
Witness to Accident:
Date of incident:
Time of incident:
A
/
/
(
)AM (
)PM
__
Date assigned to present position:
Date of hire:
Date incident reported:
To Whom:
Returned to work:
/
/
/
/
/
/
(
) Yes (
) No
S
Address where injury occurred (If different from Employer above):
Date of Return to Work:
Returned to Regular Job:
U
/
/
(
) Yes (
) No
P
Type of injury (Burn, Fracture, Cut, etc.):
Average 52 Week Wage:
E
$
(
) Estimated (
) Actual
R
Injured Body Part(s) (Arm, Leg, Back, etc.):
Source of injury (Chemicals, Machinery, etc.):
Name of Employer’s Claim Coordinator:
V
I
Height:
ft.
in.
Weight:
Smoker: (
) Yes (
) No
If yes, # pack(s) per day:
S
O
Describe what happened:
R
Supervisor Signature: _________________________________________________ Date:_____/_____/_____
S
Medical Authorization: In accordance with state law, I, the undersigned, authorize A.I.M. Mutual Insurance Companies, as a workers compensation insurer, and its
E
authorized agents or representatives, as well as my employer to be furnished with any information or facts regarding this injury only, including records, diagnosis,
C
medical treatment and prognosis, estimates of disability and recommendations for further treatment. This information is to be used for the sole purpose of evaluating
T
and handling my claim and to assure timely medical care as a result of the incident occurring on or about the above noted date and for no other purpose, now or in the
I
future. I also agree that a photocopy of this release is as valid as the original.
O
N
Employee Signature: __________________________________________________ Date: _____/_____/____
B
I do not want medical treatment for this injury – Employee Signature:
Date:
/
/
(
TREATMENT AREA USE ONLY
To be filled out by Medical Care Provider)
S
E
N ame of Provider: __________________________________________ Date: ____/____/____ Arrival Time: ______ ( )AM ( )PM
C
Accident Description: _____________________________________________________________________________________
T
I
Preliminary Diagnosis: ________________________________________________________ New Injury/Illness: (
)Yes(
)No
O
Related to above incident at work: (
)Yes (
)No (
)Undetermined
Pre-existing Condition: (
)Yes (
)No
N
Height:
ft.
in
Weight:
lbs.
Smoker: (
) Yes
(
) No
If yes, # pack(s) per day _________
C
Recommended Work Status: (Check one and provide additional information as appropriate)
__
Full Duty (
)
Modified Duty (
)
Full Duty to resume on: ______/______/______
Unable To Immediately Return To Work (
)
M
E
Modified duty to begin: ______/______/______
Full Duty to resume on: ______/______/______
D
I
May lift up to:
5 lbs. (
)
25 lbs. (
)
40 lbs. (
)
75 lbs. (
)
No lifting
(
)
C
A
May carry up to:
5 lbs. (
)
25 lbs. (
)
40 lbs. (
)
75 lbs. (
)
No carrying
(
)
L
May Push/Pull up to:
5 lbs. (
)
25 lbs. (
)
40 lbs. (
)
75 lbs. (
)
No pushing/pulling
(
)
P
Other Duty Modifications: _____________________________________________________________________________________
R
Physician Comments: ________________________________________________________________________________________
O
V
Follow-Up Appointment With: _____________________________________ Date: ____/____/____ Time: ________ ( ) AM ( ) PM
I
D
Physician/Clinician Name:________________________________________
Tel. #: (
) ______ - _________
E
(Please print legibly)
R
Physician/Clinician Signature: ___________________________________________ Date: _____/_____/_____
SUPERVISOR ACTION:
(
) Returned to Work
(
) Modified Duty (
) Send Home
(
) Send for Treatment
( ) Notice Only
(
) Medical Only (
) Lost Industry Code: _______________________ (see Instruction sheet)
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