OrthoCarolina



1070610-41275Workers’ CompensationNew Patient | Authorization Form Patient Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Patient Mailing Address: Street #, City, State FORMTEXT ?????Patient Email Address: FORMTEXT ?????Phone #: FORMTEXT ?????Social Security #: FORMTEXT ????? Date of Injury: FORMTEXT ????? Employer: FORMTEXT ?????Injured Body Part: FORMTEXT ?????Address: FORMTEXT ?????Phone#: FORMTEXT ?????Has this patient received treatment? FORMTEXT ????? Has surgery occurred for this injury? FORMCHECKBOX Yes FORMCHECKBOX NoHas the patient received X-Rays, CT, MRI etc? FORMCHECKBOX Yes FORMCHECKBOX NoCase Manager Name: please circle (Telephonic/Field) FORMTEXT ?????Phone #: FORMTEXT ?????Email Address: FORMTEXT ?????Fax #: FORMTEXT ?????WC Insurance Carrier: FORMTEXT ?????WC Claim #/ Jurisdiction: FORMTEXT ?????Billing Address: FORMTEXT ?????Bill Review Company: FORMTEXT ?????Telephone/Email Address: FORMTEXT ?????Adjuster Name: FORMTEXT ?????Email Address: FORMTEXT ?????Phone #: FORMTEXT ?????Fax #: FORMTEXT ?????Locations:CHARLOTTE SPECIALTY CENTERS: FORMCHECKBOX Foot & Ankle FORMCHECKBOX Shoulder/Elbow FORMCHECKBOX Hand FORMCHECKBOX Spine FORMCHECKBOX Hip & Knee FORMCHECKBOX Sports FORMCHECKBOX PediatricsALL OTHER LOCATIONS: FORMCHECKBOX Ballantyne FORMCHECKBOX Hickory FORMCHECKBOX Matthews FORMCHECKBOX Taylorsville FORMCHECKBOX Bennettsville FORMCHECKBOX Hudson FORMCHECKBOX Monroe FORMCHECKBOX University FORMCHECKBOX Blakeney FORMCHECKBOX Huntersville FORMCHECKBOX Mooresville FORMCHECKBOX Winston-Salem FORMCHECKBOX Boone FORMCHECKBOX Kernersville FORMCHECKBOX Pembroke FORMCHECKBOX Clemmons FORMCHECKBOX King FORMCHECKBOX Pineville FORMCHECKBOX Concord FORMCHECKBOX Lincolnton FORMCHECKBOX Rock Hill, SC FORMCHECKBOX Gastonia FORMCHECKBOX Laurinburg FORMCHECKBOX ShelbyPreferred Vendor Section:Will Ancillary Services be approved through OrthoCarolina? MRI / PHYSICAL THERAPY/ POST SURGICAL DME FORMCHECKBOX Yes FORMCHECKBOX No (if no please indicate preferred vendor) : FORMTEXT ?????By signing the authorization form you are giving authorization for patient to receive treatment with OrthoCarolina for the following: Consult, Treatment, Lab, and X-ray, EMG, NCSAdjuster Signature: FORMTEXT ?????Date: FORMTEXT ????? ................
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