Workers Compensation - Part 3 - Treatment and Insurance Info

Injuries:

State in full detail all injuries you received as a result of this accident and when these were first noticed:

When did you first seek medical treatment for your injuries?

State your present physical condition – scars, deformities, headaches, pains, etc. due to injuries received in this accident:

List all previous injuries received during your lifetime:

Medical History:

When did you first seek medical treatment for your injuries:

Were you hospitalized?

Where?

For how long?

Did you receive any type of physical therapy?

Therapists:

Date(s) of treatment:

List the full name, address and telephone number of each physician, chiropractor or dentist who has examined or treated you for your injuries as a result of the accident:

Doctor's name:

Address:

Telephone number:

Dates:

Treatment received:

List all the doctors you have seen in the past ten (10) years for any treatment:

Doctor's Name:

Address:

Telephone Number:

Dates:

Treatment:

Physical therapy/pain management:

Dates:

Furnished by:

Address:

Insurance Information:

Employers workers compensation carrier:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number:

Email address:

Fax Number:

Name of the work comp insurance representative you have dealt with:

Your Claim Number:

What is the last date you received a check from workers compensation?

Have medical benefits been paid on your behalf?

Has any other health insurance paid any of your medical bills?

Whom?

Previous Workers Compensation Claims:

Have you had prior workers compensation claims?

Please provide:

Name of employer:

Date of injury:

Injuries sustained:

State how your claim was resolved:

Client's (and Spouse's) Hospitalization (Medical Benefit) Insurance:

Health Insurance Policy #1:

Company:

Direct Purchase:

Through employer (if so, which employer):

Client:

Spouse:

How are claims filed?

Through whom?

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Group ID Number:

Member ID Number:

Coverage:

On whom?

Health Insurance Policy #2:

Company:

Direct Purchase:

Through employer (if so, which employer):

Client:

Spouse:

How are claims filed?

Through whom?

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Group ID Number:

Member ID Number:

Coverage:

On whom?

Health Insurance Policy #3:

Company:

Direct Purchase:

Through employer (if so, which employer):

Client:

Spouse:

How are claims filed?

Through whom?

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Group ID Number:

Member ID Number:

Coverage:

On whom?

Workers Compensation – Part 3 – Treatment and Insurance Info

Injuries:

Medical History:

Insurance Information:

Previous Workers Compensation Claims:

Client's (and Spouse's) Hospitalization (Medical Benefit) Insurance: