Fillable Special Exam Information Form - Orthocarolina printable pdf download

WORKERS’ COMPENSATION SPECIAL EXAM INFORMATION FORM – FAX: 704‐945‐7684

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IME : This is an Independent Medical Evaluation

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CSO: This is a Comprehensive Second Opinion

On the above, there will be no diagnostic tests performed unless the MD requires them to complete his/her evaluation.

These are one‐time evaluations only.

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CSO WITH TRANSFER OF CARE (The requesting party authorizes total and complete transfer of care.)

All evaluations consist of review of all medical records, x‐rays, and any other diagnostic studies.

PATIENT INFORMATION:

NAME: _________________________________________________________ DOB: ______________________ SSN: _________________________

ADDRESS: ____________________________________________ CITY: _________________________ STATE: __________ ZIP: ________________

HOME PHONE: ____________________________ CELL PHONE: ___________________ E‐MAIL: _________________________________________

EMPLOYER INFORMATION:

NAME: _______________________________________________________________________ PHONE: ___________________________________

ADDRESS: ______________________________________________ CITY: ______________________________ STATE: _________ ZIP: _________

BILLING INFORMATION:

PARTY SCHEDULING: ____________________________________ PHONE: ________________________ FAX: _______________________________

SCHEDULING PARTY’S E‐MAIL: ________________________________________________________________________________________________

REPORT/BILL TO: __________________________________________________________________________________________________________

ADJUSTER: ___________________________________________PHONE: ___________________________ FAX: _____________________________

ADJUSTER’S E‐MAIL: ________________________________________________________________________________________________________

CARRIER ADDRESS: ________________________________________________________________________________________________________

CITY: _________________________________________________ STATE: ___________________________________ ZIP: ____________________

JURISDICTION: _____________________ CLAIM NO. ____________________________________ DATE OF INJRY: ___________________________

BODY PART(S) TO BE EVALUATED: _____________________________________________________________________________________________

ADJUSTER/ATTORNEY/NURSE CASE MANAGER/AUTHORIZED PARTY : ________________________________________________________________

DATE: ________________________________

ORTHOCAROLINA USE ONLY

TODAY’S DATE: __________________________________OCN: ___________________________________ OC PHYSICIAN: _________________________________

APPT. DAY: ________________DATE: ______________ TIME: _____________ MD: ________________________________LOCATION: ______________________

DATE APPT. CANCELLED: __________________________ REASON: ______________________________________________________________________________

DATE APPT. RESCHEDULED: _______________________________________________________________________________________________________________

INVOICE SENT ON: ______________________ PAYMENT RECEIVED ON: __________________________________ CHECK NO.: _____________________________

Special Exam Form

Rev. 6/2015

Special Exam Information Form - Orthocarolina