WORKMEN’S COMPENSATION INTAKE FORM
WORKMEN’S COMPENSATION INTAKE FORM
Date: ___________
Appointment type requested:
|[] Consultation only |[] Treatment |[ ] 2nd Opinion |
Please complete the following:
|Patient Name: |
|Referred to: |
W/C INFORMATION
|Adjuster: |Ins.: |
|Phone: |Fax: |
|Claim Address: |
PATIENT INFORMATION
|DOI: |Type of Injury: |
|Employer: |
|Employer’s Address: |
|Job Title: |
|Claim #: |WCAB#: |
PERSONAL INFORMATION
|DOB: |SSN: |
|Address: |
|Home Phone: |Cell Phone: |
|Referred by: |
|Phone: |Fax: |
ATTORNEY INFORMATION
|Attorney’s Name: |
|Firm Name: |
|Address: |
|Phone: |Fax: |
|Nurse Case Manager: |
|Phone: |Fax: |
FAX OR MAIL COMPLETED FORM TO THE FOLLOWING:
ATTN: AUTHORIZATION COORDINATOR
1940 Webster Street, Suite 200
Oakland, CA 94612
FAX: 510 463-4722
CONTACT YOUR ADJUSTER / ATTORNEY AND HAVE THEM FORWARD YOUR MEDICAL RECORDS. APPOINTMENTS WILL NOT BE SCHEDULED WITHOUT MEDICAL RECORDS AND AUTHORIZATION FROM YOUR ADJUSTER
Please note incomplete intake forms and lack of medical records will delay the scheduling process. Our authorization coordinator will contact you directly after we have received your medical records, authorization and the requested doctor has reviewed your medical records. Please allow 3 weeks for this process. Thank you.
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