PA Federation of Injured Workers Independent Medical Exam (I.M.E.)
|
|
|
- Joan Craig
- 8 years ago
- Views:
Transcription
1 PA Federation of Injured Workers Independent Medical Exam (I.M.E.) As you know, the reason a worker s compensation insurer/self-insured employer uses an Independent Medical Exam is not to obtain an impartial review, but to obtain a medical opinion which could justify the discontinuance and/or denial of worker s compensation benefits. The I.M.E. physician was hired to prove that your are not disabled or that any disability that you have didn t come from the work injury incident you claim it came from. PREPARATION PRIOR TO THE I.M.E. 1. You should never attend an IME alone. Request to have the IME close to your home, the further away from home the exam is scheduled, the more inconvenient for you to have a friend or relative take you, stay with you, support you and bring you back home. 2. Request payment for travel to and from the IME location before you go for the IME. Do not agree to reimbursement because once you have gone through with the IME they will just deny travel expense payment. Then you have to litigate to get it. You have the right to receive payment for travel expenses. 3. Create an outline about your injury. This will keep you from getting confused. Also give a copy of the outline to the IME physician and get a copy signed by the IME physician. This way the IME physician cannot claim that you did not submit any injury history. a. Write down a brief history of what happened to you, and include the medical treatment you have received. b. List all of your symptoms related to your work injury. c. List all medications taken over the course of your medical treatment and any side effects they cause and added to your injury symptoms are prohibiting you from returning back to work. d. List all medical testing that supports your injury claim. THE DAY OF THE I.M.E. 1. Have another person present during the IME. Don t go it alone. 2. Make sure the IME physician is the same physician your were scheduled to see. 3. No rehab nurses representing the insurer/self-insured employer has a right to be present for your examination. 4. You and your witness should note the time you arrive, then the time you go into the exam room, the time the IME physician enters the exam room, the time he left the exam room and the time you left the exam room. 5. Take all of your x-rays, and other test results with you the day of the exam. Some attorneys say you can object to any invasive procedures, that includes x-rays. You should have your attorney help you make the decision on whether you will object to new tests or x-rays before your exam day. 6. If during the course of the exam, it may become necessary to lie down, use the restroom, or drink a beverage, don t hesitate to ask for anything you need and explain to the IME physician what reactions you are experiencing during the exam process, that would explain your need for this type of relief. a. It is imperative that you speak up and tell the IME physician exactly what it is that is causing pain and/or discomfort to you at any time during the exam. Time for candor not courage.
2 b. If the IME physician does not heed your explanation that a particular part of the exam is causing you pan and discomfort, have your witness/friend intercede (Tell the IME physician off) at this point and explain what it is that is causing the pain or discomfort and the need for a break. Have your witness/friend be outspoken, not shy, and able to intervene on your behalf if they feel based on your reactions that the exam id going to far or has gone to far and to lengthy and causing you to experience extreme discomfort or excruciating pain. In the event the exam process becomes so overwhelming and you feel extremely sick or are having problems with overwhelming pain, weakness, exhaustion etc. and if absolutely warranted, DO NOT HESTATE to have your witness/friend take charge of the situation and call an ambulance on your behalf and take you to the nearest emergency room. c. Take a camera to the IME exam. If your injury looks different, swollen, discolored, shiny or anything else that will show up, take a picture that shows you were at the IME exam location. Take the photo so it includes something that identifies the location and will be I the picture. An example would be a certificate on the wall, a name plate on a desk or the business sign for the facility. 7. Be on time and dress neatly. You want to make a favorable impression. Be courteous to the IME physician and staff. Don t exaggerate of fake any injuries or any part of the examination. These exams are designed to detect faking. 8. Before you leave the IME location request that any report generated by the IME physician be simultaneously forwarded to you and your treating physician and put that request in writing and get a signature on a copy of the request for your records. AFTER THE IME IS COMPLETED 1. After the examination is over, make some general notes. If you have an attorney call and let them know what happened while it is fresh in your memory. 2. You should see your treating physician the same day you see the IME physician. Make sure you have scheduled the appointment time for your treating physician to occur after the IME examination. Your treating physician will be able to say what was found on the same day you saw the IME physician. Some times the IME physicians examination will hurt you and your treating physician should be able to document the aggravation of your injury. This is important to detect any sort of medical malpractice that may have occurred during he IME exam. 3. Request a copy of the IME report from the worker s compensation insurer s/self-insured employer s compensation claim agent. Allow 15 days for the report to be received. In some instances the worker s compensation insurer/self-insured employer cannot use medical testimony of that IME physician if the worker s compensation insurer/self-insured employer fails to provide an IME report within 15 days. 4. When received make sure all of the IME reports are the same. Sometimes reports have a way of changing. If they are different and you have an attorney contact him/her immediately to report the discrepancy. ADDITIONAL I.M.E. FACTS If the curriculum vitea of the proposed IME physician does not seem to be suitable for evaluating your injury, then in writing by certified return receipt, request the worker s compensation insurer/self-insured employer provide an IME physician who has more background, training, experience and treats patients who have been disabled by the disease and condition which disables you. Ask the IME physician how much he/she is being paid to perform the exam and report and document it. Document any conversations you have with the IME physician or any member of his/her staff.
3 The IME exam begins as soon as you enter the parking lot of the IME exam location. There may be video cameras covering the parking lot. The IME staff will be watching the entire time you are in the Office. They will watch everything you do. You need to be as observant while you are there and document everything you remember as soon as you leave. Do not volunteer any information about past injuries, medical history, past claims or family information. If the IME physician does not ask for it don t give it. Do not permit more then one IME physician to examine you. Do not allow any laboratory tests, puncturing of skin or taking of blood or urine unless the IME physician obtains your attorneys written permission. Do not sign any papers, records or documents unless it is a simple questionnaire asking for basic information such as name, address, date of birth, date of the work injury, names of treating physicians or basic information of this nature. Do not talk to the IME physician about the status of your workers compensation case, the insurer/self-insured employer, attorneys or insurance adjuster. Fill out an IME Questionnaire as soon as the IME exam is completed.
4
5 Time you arrived: I.M.E. QUESTIONAIRE Time exam started: Time exam ended: Who did you talk to I the IME office? Did you take any medications on the date of the exam? If yes, please describe Did the IME physician ask about your medications? HISTORY Who took your injury medical history? How long did the history-taking last? How was the history taken? Written Recording What did you tell the IME physician about your history? PHYSICAL EXAMINATION Attach separate sheet if needed How was the IME exam documented? Written Recording Length of time for the IME examination (The time the physician started to examine you not including the time you spent in the exam room waiting): Remarks made by the IME physician during the examination to you or others: (Including any references to your claim for injuries.):
6 Attach separate sheet if needed Did the IME physician examine your: Eyes Ears (hearing test) Nose (smelling test) Throat Neck Was your temperature taken? Heart Movements Back Legs Other Describe all bending, moving, lifting, reaching and turning done during the IME examination Were any measurements of any part of your body measured? If yes, which part of the body? TESTS PERFORMED Were x-rays taken? If yes, of what part of the body? Were any other tests performed? If yes, please describe
7 Were you asked to exercise on any equipment or machine? If yes, please describe EFFECTS OF TESTS OR EXAM Did you notice any numbness during or after the exam? Did any of the tests/exams cause you to feel pain? If yes, please describe Attach separate sheet if needed CONVERSATIONS WITH THE IME PHYSICIAN After the IME examination, did the physician ask you how you were feeling? If yes, what was your response? Did the IME physician tell you anything about your injuries? If yes, please explain What was your overall impression of the IME physician during the examination? FOR ADDITIONAL COMMENTS
8
INDEPENDENT MEDICAL EXAM (IME)
INDEPENDENT MEDICAL EXAM (IME) As you know, the purpose of the Insurance Company is not to obtain an impartial review, but to obtain a medical opinion which could justify the discontinuance and/or denial
WORKERS' COMPENSATION CLAIMANT INFORMATION PACKET
WORKERS' COMPENSATION CLAIMANT INFORMATION PACKET Instructions Statement of Rights Prescription ID and Pharmacy Information The New York State Insurance Fund TLC EMERGENCY MEDICAL SERVICES Inc. TLC MEDICAL
Emergency Room (ER) Visits: A Family Caregiver s Guide
Family Caregiver Guide Emergency Room (ER) Visits: A Family Caregiver s Guide Your family member may someday have a medical emergency and need to go to a hospital Emergency Room (ER), which is also called
Patient Information: In Case of Emergency: Physician: Insurance:
For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:
Radiation Therapy for Palliative Treatment at The Carlo Fidani Peel Regional Cancer Centre
Radiation Therapy for Palliative Treatment at The Carlo Fidani Peel Regional Cancer Centre Introduction...2 Patient Education and Information...2&3 Treatment Planning...3&4 Your Appointments...5 Radiation
HOW TO REPRESENT YOURSELF IN A MEDICAL DISABILITY HEARING AT THE DEPARTMENT OF SOCIAL SERVICES
HOW TO REPRESENT YOURSELF IN A MEDICAL DISABILITY HEARING AT THE DEPARTMENT OF SOCIAL SERVICES If you are age 65 or older OR you have minor children living with you (under age 18), you can receive Medicaid
Cervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
WHAT CAN I DO WHEN I HURT MYSELF AT WORK?
WHAT CAN I DO WHEN I HURT MYSELF AT WORK? This booklet is to help you when you are injured on the job 1 Name of WSIB Representative: Date of Injury: Supervisor: Witnesses: What happened (date and time,
How To Tell Someone You Were Injured In A Car Accident
Personal Injury Questionnaire Answer each question fully and accurately. Success in this case depends on mutual confidence and complete cooperation between you (as the client) and the attorney. It is imperative
(This is a sample of the injury packet that GENEX will customize for each employer)
Ohio Workers Compensation Injury Packet (This is a sample of the injury packet that GENEX will customize for each employer) Employer: «Employer» «Address1» «City», «ST» «Zip» Phone #: «Phone» BWC Policy
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
A Consumer Guide. What is a Deposition and How Does It Work in a Personal Injury Case?
79 Wall Street Huntington, NY 11743 800.660.1466 631.425.9775 718.220.0099 631.415.5004 (fax) A Consumer Guide What is a Deposition and How Does It Work in a Personal Injury Case? A key component in many
Workers Compensation: Making a claim
Workers Compensation: Making a claim What are workers compensation benefits? Workers compensation benefits are payments for injuries or diseases that are related to the work you were doing. Workers compensation
11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
Personal Injury Questionnaire
Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer
Information for Worker s Compensation Clients
Information for Worker s Compensation Clients Overview of the Worker s Compensation Act Indiana Worker s Compensation cases are governed by a State law known as the Worker s Compensation Act. The legislature
Top 10 Mistakes Made After A Car Accident. www.chaikinandsherman.com 202.659.8600 800.299.8384
Top 10 Mistakes Made After A Car Accident www.chaikinandsherman.com 202.659.8600 800.299.8384 1 In this Top Ten List, we have drawn upon our decades of experience in handling car accident cases to compile
Coding for the Internist: The Basics
Coding for the Internist: The Basics Evaluation and management is the most important part of the practice for an internist and coding for these visits can have an important effect for the bottom line of
ACCIDENT HISTORY QUESTIONNAIRE
ACCIDENT HISTORY QUESTIONNAIRE PATIENT INFORMATION Name Date Address City State Zip Code DOB Age SS# Marital Status Sex Male Female How did you hear about the office? Home Phone Work Phone Employer Occupation
Your Health Insurance: Questions and Answers
Your Health Insurance: Questions and Answers This simple guide will help you understand how to use and keep your health insurance Meet four people with questions about their health insurance: George is
Copayment Is Due At Time Of Visit. Self-pay (payment due at time of service)
REGISTRATION FORM Please present your insurance card and photo ID at time of check-in. Settlement of patient financial responsibility is expected at time of service. Copayment Is Due At Time Of Visit.
Colorado Personal Injury and Disability Lawyer. Auto Accident Victim s TOOLKIT. Call Now! 877-846-4878 www.mcdivittlaw.com
Auto Accident Victim s TOOLKIT Call Now! 877-846-4878 www.mcdivittlaw.com 1 Auto Accident Victim s Toolkit An auto accident is overwhelming and the days following it are trying and confusing while dealing
Personal Accident Claim Form
Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Personal Accident Claim Form
let s talk bleeds a bleed checklist for haemophilia patients
let s talk bleeds a bleed checklist for haemophilia patients Specific signs of a bleed Watch for Bruising, with or without lumps Difference in the size of arms/legs Difference in movement in arms/legs
16 Steps to Getting a Fair Settlement for Your Injuries
The Petrylaw Personal Injury Reports 16 Steps to Getting a Fair Settlement for Your Injuries 1. Do not talk to anyone except your doctor, attorney or the police officer at the scene. Do not speak with
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
Diuretics: You may get diuretic medicine to help decrease swelling in your brain. This may help your brain get better blood flow.
Hemorrhagic Stroke GENERAL INFORMATION: What is a hemorrhagic stroke? A hemorrhagic stroke happens when a blood vessel in the brain bursts. This may happen if the blood vessel wall is weak, or sometimes
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?
Personal Accident and Sickness Claim Form
Please return claim form to: Corporate Services Network 2 / 280 George Street Sydney NSW 2000 Ph: +61 2 8256 1770 Fax: +61 2 8256 1775 E-mail: claims@csnet.com.au Employer: Claimants Name: Job Title: Work
PERSONAL INJURY QUESTIONNAIRE. NAME: Date of Accident
PERSONAL INJURY QUESTIONNAIRE NAME: Date of Accident Where did accident happen? Describe the accident in your own words: What was your position in the car? Driver: if Driver were your hands on the steering
Medicare Health Risk Assessment Questionnaire
Medicare Health Risk Assessment Questionnaire Instructions: Please complete and return it in the self-addressed stamped envelope provided. If you have questions or need help completing the questionnaire,
MDwise Right Choices Program
Welcome to the MDwise Right Choices Program Helping you get the right care at the right time at the right place. MDwise Right Choices Program What is the Right Choices program? The Right Choices program
Patient Guide. A Winnipeg Health Region Hospital
Emergency Department Patient Guide Information FOR PATIENTS & Their FAMILIES in SEVEN OAKS GENERAL HOSPITAL s EMERGENCY DEPARTMENT A Winnipeg Health Region Hospital If You Have a Concern about Your Care,
Medical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
Learning How To Be Your Own Best Advocate
Learning How To Be Your Own Best Advocate The Impor tance of Medical Evidence in Personal Injur y Claims Managing Your Medical Treatment After An Accident By Chris Davis, Attorney at Law Davis Law Group,
Headache after an epidural or spinal injection What you need to know. Patient information Leaflet
Headache after an epidural or spinal injection What you need to know Patient information Leaflet April 2015 We have produced this leaflet to give you general information about the headache that may develop
How To Get A Physical Therapy At West Point Physical Therapy Center
Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA 93551 (661)265-0060 To our workers compensation patients: Cathedral City 68-845 Perez Rd., Ste. H6-H7 Cathedral City, Ca 92234 (760)328-0292 California
Worker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
The Insurance and Whiplash Guide I Hope You ll Never Have To Use But If You Do You ll Be Glad You Read This First!
The Insurance and Whiplash Guide I Hope You ll Never Have To Use But If You Do You ll Be Glad You Read This First! A special thanks goes to Dr. Steven Eggleston, DC, Esq. for his expertise and his years
EMPLOYEES GUIDE TO APPEALING A WORKERS COMPENSATION CLAIM DENIAL
EMPLOYEES GUIDE TO APPEALING A WORKERS COMPENSATION CLAIM DENIAL Appeals of workers compensation claim denials are handled by the Labor Commission s Adjudication Division. If you disagree with the claim
ADVANCE DIRECTIVE Your Durable Power of Attorney for Health Care, Living Will and Other Wishes
Introduction: ADVANCE DIRECTIVE Your Durable Power of Attorney for Health Care, Living Will and Other Wishes This document has been prepared and distributed as an informational service of the District
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
IN THE COMMONWEALTH COURT OF PENNSYLVANIA
IN THE COMMONWEALTH COURT OF PENNSYLVANIA James Conace, : Petitioner : : v. : : Workers Compensation Appeal : Board (Armen Cadillac, Inc.), : Nos. 346 & 347 C.D. 2014 Respondent : Submitted: September
Information for Patients. Advance Health Care Directive Kit A guide to help you express your health care wishes
Information for Patients Advance Health Care Directive Kit A guide to help you express your health care wishes Table of contents PART I - REQUIRED Selection of a decision maker Who will make health care
7% - 1 /% % 1.14 0 "1,( (1,( 14 - "!#% #"!A(" "4:2 4!(!2"= B"!2 #!B! !("! B!!2"!!"!" -2!
7% -!"!#$$ %&" '()* +,- *+$./- *+$#-*+$ 0 & - 1,-1./-1#-10!1121 1(1.31-2!21021(14 1 /% % 1.14 0 "1,( (1,( 14,35!,%#!61#1,(01141-1-"&-" 1-%11( -" 171.!153-2 -- "-8 -#1#&(19!1&&:1-! &(";!"./
Treating Mesothelioma - A Quick Guide
Treating Mesothelioma - A Quick Guide Contents This is a brief summary of the information on Treating mesothelioma from CancerHelp UK. You will find more detailed information on the website. In this information
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
WARNKEN, LLC Attorneys at Law 2 Reservoir Circle Suite 104 Pikesville, Maryland 21208-1391 443-921-1100 443-921-1111 (fax) www.warnkenlaw.
WARNKEN, LLC Attorneys at Law 2 Reservoir Circle Suite 104 Pikesville, Maryland 21208-1391 443-921-1100 443-921-1111 (fax) www.warnkenlaw.com Starting Your Workers Compensation Case Dear Potential Client:
Personal Injury Questionnaire
Welcome to Chiro Spa, we are looking forward to serving you to a lifetime of wellness. Personal Injury Questionnaire Name Nick Name: Email: Address City State Zip Best two (2) phone numbers to reach you
HISTORY OF PRESENT ILLNESS
d/b/a Guggino Eye Center 3115 W. Swann Ave., Tampa, FL 33609 (813) 879-7711 13904 N. Dale Mabry Hwy., Suite 200, Tampa, FL 33618 (813) 908-2020 3205 Physicians Way, Sebring, FL 33870 (863) 385-1544 HISTORY
Florida Workers' Compensation Depositions
DENNIS A. PALSO workers compensation board certified DENNIS A. PALSO, P.A. ATTORNEY AT LAW Gateway Pines Executive Park 710-94 th Avenue North Suite 309 St. Petersburg, Florida 33702 Telephone (727) 578-5911
WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured?
WHAT SHOULD I DO IF I HAVE AN AUTO ACCIDENT? 1. If I have an auto accident, do I have to stop? 2. What should I do if someone is injured? 3. How can I get help? 4. What information should I gather at the
Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Journal. A workbook designed to organize and survey your incident & injury throughout the road to recovery. tywilsonlaw.
YOUR INJURY Journal A workbook designed to organize and survey your incident & injury throughout the road to recovery SLIP/FALL CAR ACCIDENT WORKERS COMP TY WILSON LAW tywilsonlaw.com 866-937-5454 YOUR
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
New Patient Questionnaire
New Patient Questionnaire Name: Date: Age: Date of Birth: Right or Left Handed: Height: Weight Primary Care Doctor: Address and Phone number: Occupation (If working): Current work status (full duty, light
Accident/Incident & Workers Compensation. Packet
Accident/Incident & Workers Compensation Packet Accident/Incident & Workers Compensation Program The following information is to assist you in completing the Accident/Incident & Workers Compensation Program
Managing your health care benefits on myuhc.com
Managing your health care benefits on myuhc.com Managing your health care benefits and communications online is easy and convenient on myuhc.com We ve made it easier for you to manage your health care
MISCONDUCT INCIDENT REPORT
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Quality Assurance DHS 13.05(3)(a), Wis. Admin. Code F-62447 (Rev. 04/10) Page 1 of 8 MISCONDUCT INCIDENT REPORT GENERAL INSTRUCTIONS Use this
Employee Guidelines for Workers Compensation Accidents
Employee Guidelines for Workers Compensation Accidents The information included in this packet will become important to you in the event that you seek medical attention or lose time from work due to a
Want to choose the person making health care for you yourself? Then fill out the Appointment of Health Care Agent paper inside this brochure.
August 2014 What Tennesseans Need to Know About Appointing a Health Care Agent (Durable Power of Attorney for Health Care) and Making an Advance Health Care Plan (Living Will) Why is this important? People
Report ALL on-the-job injuries to
1817 N. Stewart Street, Suite 20 Carson City, NV 89706 Phone: 775-283-0040 Toll Free: 888-873-4234 Fax: 775-283-0035 Report ALL on-the-job injuries to Tri-Odyssey Risk Management Department Phone: 775-283-0040
Personal Accident and Sickness Claim Form
Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Employer: Claimants Name: Job
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security
Emergency Assistance Phone Numbers:
Thank you for purchasing the IMG OUTREACH Plan. This document includes tips for team leaders and travelers as well as resources for filing a successful claim. We highly recommend reviewing and printing
The Seubert Safe Workplace
The Seubert Safe Workplace The Seubert Safe Workplace is a program initiated to help our commercial insurance clients their control worker compensation costs and improve employee health and well-being.
Medical Records Analysis
Medical Records Analysis Karen A. Mulroy, Partner Evans & Dixon, L.L.C. The analysis of medical legal issues posed in any case can be complicated, requiring some close reading and detective work to both
Patient Name: Patient Signature:
HIPAA PRIVACY POLICY 3518 Riverside Dr. Suite 104, Upper Arlington, OH 43221 Name: Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how
How To Get Workers Compensation Benefits In Massachusetts
If you are having health problems because of your job, you have a right to benefits. Here s what you need to know about: Workers Compensation in Massachusetts If you are injured or become ill because of
Index. Index LEARNING. Page 1. Level 1. Sending a Fax. Explaining your Job. Doing your Job. Making a Contact List. Level 2. Looking after Yourself
Index Level 1 Sending a Fax Explaining your Job Doing your Job Making a Contact List Level 2 Looking after Yourself Using Computers Using the Internet Keeping a Diary Following a Plan Level 3 Managing
TOP 10 SOCIAL SECURITY DISABILITY QUESTIONS
TOP 10 SOCIAL SECURITY DISABILITY QUESTIONS 1. How do I apply for Social Security? You can apply for it over the phone, over the internet or in person. If you are disabled and cannot work, do not wait.
Health Insurance for International Visiting Scholars & Faculty
Health Insurance for International Visiting Scholars & Faculty Health Insurance is required while you are working/researching at Stony Brook University. United States Federal Law requires you have adequate
PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE
PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE TODAY S DATE: PERSONAL INFORMATION: NAME: (home) (cell) Age: Date of Birth: Social Security No: EMPLOYER: (work) Occupation: Worked there how long? Immediate
Wisconsin Worker's Compensation Basics Information Every Wisconsin Worker Should Know if Injured
Wisconsin Worker's Compensation Basics Information Every Wisconsin Worker Should Know if Injured By Attorney Stuart J. Spaude Bollenbeck Fyfe, S.c. W6260 Communication Ct. Appleton, WI 54914 (920) 735-1711
2014 Honor System Consulting
1 Managing Attorney, Lien Unit Floyd Skeren & Kelly LLP Owner of Honor System Consulting Prior Manager of the Division of Workers Compensation Medical Unit, in charge of the QME program, MPN, Independent
Cardiac Catheter Lab Information for patients having a Coronary Angiogram
Cardiac Catheter Lab Information for patients having a Coronary Angiogram Page 1 of 5 What is a Coronary Angiogram? This is a test that uses dye and special x-rays to show the inside of your coronary arteries.
County Court Restraining Orders
Answers to Your Questions About County Court Restraining Orders Excellence in Customer Service Colorado Judicial Branch http://www.courts.state.co.us June 2002 CIVIL LAW In a civil case, the person seeking
PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM
Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document
*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM
Oasis Chiropractic Injury/ Auto Accident/ Slip & Fall Form First Name: Last Name: Title: (check one) Mr. Mrs. Ms. Miss Dr. Other Patient ID#: Single Married Widowed Under 18 (Minor) Separated Divorced
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
Next Level Physical Therapy PC Patient Information
Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home
Discharge Information after a Coronary Angiogram or Coronary Angioplasty/ Stent Procedure
Discharge Information after a Coronary Angiogram or Coronary Angioplasty/ Stent Procedure FORM # W-00500 June 2014 Discharge Information after a Coronary Angiogram or Coronary Angioplasty/ Stent Procedure
ANESTHESIA. Anesthesia for Ambulatory Surgery
ANESTHESIA & YOU Anesthesia for Ambulatory Surgery T oday the majority of patients who undergo surgery or diagnostic tests do not need to stay overnight in the hospital. In most cases, you will be well
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
PATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
(404) 919-9756 david@davidbrauns.com www.davidbrauns.com
You are probably reading this guide because you were recently in an automobile accident. Now you are faced with some difficulties. The tasks of managing your care and your insurance claim can be confusing
South Carolina. The information below applies only to South Carolina. 1. How can I find out if I have a IV-D child support case in this state?
South Carolina Office of Child Support Enforcement Administration for Children & Families U.S. Department of Health and Human Services Changing a Child Support Order in Your State The information below
Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional
Incident/Injury Reporting and Investigation Policy Township of Tudor and Cashel
A. Policy Statement The is committed to the health and safety of employees, contractors, visitors and the general public. All incidents/injury shall be investigated to the extent warranted by their severity
Get the Facts About. Disease
Get the Facts About TB TUBERCULOSIS Disease What s Inside: 3 PAGE Get the facts, then get the cure 4 PAGE 9 PAGE 12 PAGE Learn how TB is spread Treatment for TB disease Talking to family and friends about
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip: