This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal evaluation.
|
|
|
- Sharleen Cox
- 8 years ago
- Views:
Transcription
1 This form is required to be used for ratings prepared pursuant to the 1997 Permanent Disability Rating Schedule. It is designed to be used by the primary treating physician to report the initial evaluation of permanent disability to the claims administrator. It should be completed if the patient has residual effects from the injury or may require future medical care. In such cases, it should be completed once the patient s condition becomes permanent and stationary. This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal evaluation. Patient: Last Name Middle Initial First Name Sex Date of Birth Address City State Zip Occupation Social Security No. Phone No. Claims Administrator/Insurer: Name Claim No. Phone No. Address City State Zip Employer: Name Phone No. Address City State Zip You must address each of the issues below. You may substitute or append a narrative report if you require additional space to adequately report on these issues. Date of Injury Last date Date of current Permanent & Date worked Date examination Date Stationary date Date Description of how injury/illness occurred (e.g. Hand caught in punch press; fell from height onto back; exposed 25 years ago to asbestos): Patient s Complaints: STATE OF CALIFORNIA 1
2 Relevant Medical History: Objective Findings: Physical Examination: (Describe all relevant findings; include any specific measurements indicating atrophy, range of motion, strength, etc.; include bilateral measurements - injured/uninjured - for upper and lower extremity injuries.) Diagnostic tests results (X-ray/Imaging/Laboratory/etc.) Diagnoses (List each diagnosis; ICD-9 code must be included) ICD Yes No Cannot Determine Can this patient now return to his/her usual occupation? If not, can the patient perform another line of work? 2
3 Subjective Findings: Provide your professional assessment of the subjective factors of disability, based on your evaluation of the patient s complaints, your examination, and other findings. List specific symptoms (e.g. pain right wrist) and their frequency, severity, and/or precipitating activity using the following definitions: Severity: Frequency: Minimal pain - an annoyance, causes no handicap in performance. Slight pain - tolerable, causes some handicap in performance of the activity precipitating pain. Moderate pain - tolerable, causes marked handicap in the performance of the activity precipitating pain. Severe pain - precludes performance of the activity precipitating pain. Occasional - occurs roughly one fourth of the time. Intermittent - occurs roughly one half of the time. Frequent - occurs roughly three fourths of the time. Constant - occurs roughly 90 to 100% of time. Precipitating activity: Description of precipitating activity gives a sense of how often a pain is felt and thus may be used with or without a frequency modifier. If pain is constant during precipitating activity, then no frequency modifier should be used. For example, a finding of moderate pain on heavy lifting connotes that moderate pain is felt whenever heavy lifting occurs. In contrast, intermittent moderate pain on heavy lifting implies that moderate pain is only felt half the time when engaged in heavy lifting. Pre-Injury Capacity Are there any activities at home or at work that the patient cannot do as well now as could be done prior to this injury or illness? Yes No Cannot determine If yes, please describe pre-injury capacity and current capacity (e.g. used to regularly lift a 30 lb. child, now can only lift 10 lbs.; could sit for 2 hours, now can only sit for 15 mins.)
4 Preclusions/Work Restrictions Yes No Cannot determine Are there any activities the patient cannot do? If yes, please describe all preclusions or restrictions related to work activities (e.g. no lifting more than 10 lbs. above shoulders; must use splint; keyboard only 45 mins. per hour; must have sit/stand workstation; no repeated bending). Include restrictions which may not be relevant to current job but may affect future efforts to find work on the open labor market (e.g. include lifting restriction even if current job requires no lifting; include limits on repetitive hand movements even if current job requires none) Medical Treatment: Describe any continuing medical treatment related to this injury that you believe must be provided to the patient. ( Continuing medical treatment is defined as occurring or presently planned treatment.) Also, describe any medical treatment the patient may require in the future. ( Future medical treatment is defined as treatment which is anticipated at some time in the future to cure or relieve the employee from the effects of the injury.) Include medications, surgery, physical medicine services, durable equipment, etc. Comments: 4
5 Apportionment: Effective April 19, 2004, apportionment of permanent disability shall be based on causation. Furthermore, any physician who prepares a report addressing permanent disability due to a claimed industrial injury is required to address the issue of causation of the permanent disability, and in order for a permanent disability report to be complete, the report must include an apportionment determination. This determination shall be made pursuant to Labor Code Sections 4663 and 4664 set forth below: Labor Code Section Apportionment of permanent disability; Causation as basis; Physician's report; Apportionment determination; Disclosure by employee (a) Apportionment of permanent disability shall be based on causation. (b) Any physician who prepares a report addressing the issue of permanent disability due to a claimed industrial injury shall in that report address the issue of causation of the permanent disability. (c) In order for a physician's report to be considered complete on the issue of permanent disability, it must include an apportionment determination. A physician shall make an apportionment determination by finding what approximate percentage of the permanent disability was caused by the direct result of injury arising out of and occurring in the course of employment and what approximate percentage of the permanent disability was caused by other factors both before and subsequent to the industrial injury, including prior industrial injuries. If the physician is unable to include an apportionment determination in his or her report, the physician shall state the specific reasons why the physician could not make a determination of the effect of that prior condition on the permanent disability arising from the injury. The physician shall then consult with other physicians or refer the employee to another physician from whom the employee is authorized to seek treatment or evaluation in accordance with this division in order to make the final determination. (d) An employee who claims an industrial injury shall, upon request, disclose all previous permanent disabilities or physical impairments. Labor Code section Liability of employer for percentage of permanent disability directly caused by injury; Conclusive presumption from prior award of permanent disability; Accumulation of permanent disability awards (a) The employer shall only be liable for the percentage of permanent disability directly caused by the injury arising out of and occurring in the course of employment. (b) If the applicant has received a prior award of permanent disability, it shall be conclusively presumed that the prior permanent disability exists at the time of any subsequent industrial injury. This presumption is a presumption affecting the burden of proof. (c)(1) The accumulation of all permanent disability awards issued with respect to any one region of the body in favor of one individual employee shall not exceed 100 percent over the employee's lifetime unless the employee's injury or illness is conclusively presumed to be total in character pursuant to Section As used in this section, the regions of the body are the following: 5
6 (A) Hearing. (B) Vision. (C) Mental and behavioral disorders. (D) The spine. (E) The upper extremities, including the shoulders. (F) The lower extremities, including the hip joints. (G) The head, face, cardiovascular system, respiratory system, and all other systems or regions of the body not listed in subparagraphs (A) to (F), inclusive. (2) Nothing in this section shall be construed to permit the permanent disability rating for each individual injury sustained by an employee arising from the same industrial accident, when added together, from exceeding 100 percent. Is the permanent disability directly caused, by an injury or illness arising out of and in the course of employment? Yes No Is the permanent disability caused, in whole or in part, by other factors besides this industrial injury or illness, including any prior industrial injury or illness? If the answer to the second question is yes, provide below: (1) the approximate percentage of the permanent disability that is due to factors other than the injury or illness arising out of and in the course of employment; and (2) a complete narrative description of the basis for your apportionment finding. If you are unable to include an apportionment determination in your report, state the specific reasons why you could not make this determination. You may attach your findings and explanation on a separate sheet. 6
7 List information you reviewed in preparing this report, or relied upon for the formulation of your medical opinions: Medical Records: Written Job Description: Other: 7
8 Primary Treating Physician (original signature, do not stamp) I declare under penalty of perjury that this report is true and correct to the best of my knowledge, and that I have not violated Labor Code Signature: Cal. Lic. # : Executed at: Date: (County and State) Name (Printed): Specialty: Address: City: State: Zip: Telephone: 8
Template Medical-Legal Report -Workers Compensation
California Orthopaedic Association Template Medical-Legal Report -Workers Compensation This document is presented as a template of the required elements of an orthopaedic QME/AME report. It is provided
FRESNO COUNTY EMPLOYEES RETIREMENT ASSOCIATION. Applicant Name: JOHN DOE Appointment Date: 01-01-10
FRESNO COUNTY EMPLOYEES RETIREMENT ASSOCIATION REFERRAL FOR INDEPENDENT MEDICAL EXAMINATION Applicant Name: JOHN DOE Appointment Date: 01-01-10 Time: 3:00 p.m. Date Name of Doctor Address Dear Dr.. On
Short Term Disability Claim Form. Filing Instructions
Have you Filing Instructions 1. Completed the Claimant Information Section in full? 2. Had the physician treating you complete the Attending Physician s Section, and had it returned to you? 3. Had your
PREDESIGNATION OF PERSONAL PHYSICIANS AND REPORTING DUTIES OF THE PRIMARY TREATING PHYSICIAN REGULATIONS
PREDESIGNATION OF PERSONAL PHYSICIANS AND REPORTING DUTIES OF THE PRIMARY TREATING PHYSICIAN REGULATIONS Title 8, California Code of Regulations Chapter 4.5. Division of Workers Compensation Subchapter
STATEMENT OF RECOVERY OR RETURN TO WORK
STATEMENT OF RECOVERY OR RETURN TO WORK DISABILITY INCOME CLAIM INSTRUCTIONS (PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE) Please answer all questions on the Member Statement
Helpful Hints Regarding Your Claim
Short-term Disability Claim Form Instructions EPIC s Short Term Disability Claim Form has three sections you (the employee), your employer, and your attending physician(s) must each complete your corresponding
SERIOUS INJURY ASSESSMENT REPORT RAF 4
(a) (b) (c) (d) (e) (f) (g) A claim for non-pecuniary loss ( general damages or pain and suffering ) will not be considered unless this report is duly completed and submitted. The Road Accident Fund Act
Medical-Legal Fee Schedule Tutorial
Medical-Legal Fee Schedule Tutorial For dates of service on or after July 1, 2006 Presented by Suzanne Honor-Vangerov Workers Compensation Manager DWC Medical Unit Definitions Abbreviations used in this
Short Term Disability Benefits Income Claim Form
This application package is divided into four sections, as follows: Section I Employer s Statement - to be completed by the employer s authorized representative. Section II Employee s Statement - to be
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
California Provider Reference Manual Introduction and Overview of Medical Provider Networks (CA MPNs)
California Provider Reference Manual Introduction and Overview of Medical Provider Networks (CA MPNs) Coventry/First Health has designed this manual for The Coventry/First Health Network providers participating
Short-Term Disability Claim Form
Short-Term Disability Claim Form Mutual of Omaha Insurance Company United of Omaha Life Insurance Company S-1 Group Disability Management Services Mutual of Omaha Plaza Omaha, NE 68175-0001 800-877-5176
Humana short-term income protection claim form
Humana short-term income protection claim form 1-866-836-6144 Instructions Please read and follow the instructions carefully. 1. If this is the initial claim for benefit payments for this disability, please
CLIENT INFORMATION SHEET CITY: STATE: ZIP: DOB: SEX: E-MAIL ADDRESS: EMPLOYER: PHONE ADDRESS: FELONY CONVICTIONS?
CLIENT INFORMATION SHEET DATE: NAME: REFERRED BY: ADDRESS: CITY: STATE: ZIP: PHONE: (H) (EMERG) (CELL) DOB: SEX: E-MAIL ADDRESS: SS#: SPOUSE EMPLOYER: PHONE ADDRESS: OCCUPATION: WEEKLY EARNINGS: FELONY
HARTFORD LIFE INSURANCE COMPANY HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY APPLICATION FOR SHORT TERM DISABILITY INCOME BENEFITS
Please return to: CBIA Insurance Operations 350 Church Street, Hartford, CT 06103 fax: 860-278-0883 HARTFORD LIFE INSURANCE COMPANY HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY APPLICATION FOR SHORT TERM
How To Get A Disability Check From A Health Insurance Company
INSURED'S ADDRESS (Home Address) Leaders Life Insurance Company Bloomfield, CT 06002 (888) 342-7979 PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF YOUR CLAIM. INSTRUCTIONS:
YOUR DISABILITY CLAIM
YOUR DISABILITY CLAIM This claim form is used when claiming for benefit provided by your individual disability policy or for Waiver of Premium Benefit on your life insurance policy. At Great-West Life,
A Guide for Successfully Completing the Group Short Term Disability Claim Form
A Guide for Successfully Completing the Group Short Term Disability Claim Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you
HARTFORD LIFE INSURANCE COMPANY HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS
Mail to: The Hartford Benefit Management Services PO Box 4925 Syracuse, NY 13221-4925 HARTFORD LIFE INSURANCE COMPANY HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY APPLICATION FOR LONG TERM DISABILITY INCOME
Premier Healthcare of Placerville
Premier Healthcare of Placerville 1980 Broadway, Placerville, CA 95667 (530) 622-3536 Fax (530) 622-3538 WORKERS COMPENSATION INJURY QUESTIONNAIRE Name: Social Security#: of Birth: Today s : To insure
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS)
WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS) EMPLOYEE S NAME: (last) (first) EMPLOYEE S ADDRESS: (no.) (street) (city) (state) (zip) TELEPHONE: Home: Work: SOCIAL SECURITY NO.
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
Sun Life Assurance Company of Canada
Sun Life Assurance Company of Canada Long-Term Disability Claim Packet Attending Physician Instructions for the Attending Physician Please be sure to submit the Attending Physician s Statement directly
For use with policies issued by the following Unum Group [ Unum ] subsidiaries:
![For use with policies issued by the following Unum Group [ Unum ] subsidiaries:](/thumbs/24/4004607.jpg "For use with policies issued by the following Unum Group [ Unum ] subsidiaries:")
For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company The Paul Revere Life Insurance Company
CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
DIVISION OF TEMPORARY DISABILITY INSURANCE CLAIM FOR DISABILITY BENEFITS (DS-1) DETACH THIS PAGE AND KEEP FOR YOUR RECORDS CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
Please review the applicable anti-fraud statements on the reverse side of this form.
PO Box 25, Bloomfield, CT 06002 (800) 722-9680 (860) 761-1830 www.dispec.com APPLICATION FOR CONTINUED LIFE INSURANCE COVERAGE UNDER WAIVER OF PREMIUM EMPLOYER S STATEMENT This statement must be fully
State of Florida Group Long Term Disability Claim Form
State of Florida Account Participating Agencies and Departments Payroll Deduction Code 0300 Mail To: Cigna P.O. Box 16491 Pittsburgh, PA 15242-0791 1-800-238-2125 Toll Free Claims administered by Cigna
Claim Statement for Short Term Disability Income Benefits Kanawha Insurance Company
This application package is divided into four sections, as follows: Section I Employer s Statement - to be completed by the employer s authorized representative Section II Employee s Statement - to be
INITIAL ATTENDING PHYSICIAN S STATEMENT
INITIAL ATTENDING PHYSICIAN S STATEMENT Instructions to the Insured: Please complete, sign and date Section 1. Ask your physician to complete Section 2. Please note that you, the Insured, are responsible
Workplace Voluntary Disability Claim Form Filing Instructions
Workplace Voluntary Disability Claim Form Filing Instructions The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this authorization as We
Workplace Voluntary Disability Claim Form Filing Instructions
Workplace Voluntary Disability Claim Form Filing Instructions Page One Filing Instructions Complete the appropriate sections of the claim form. Include the signed and dated authorization. Submit to the
ATTENTION MEDICARE PATIENTS: Are you currently receiving home health care? Yes No HAVE YOU BEEN SEEN IN ANY OF OUR CLINICS BEFORE?
ACTION POTENTIAL Today's Date: ATTENTION MEDICARE PATIENTS: Are you currently receiving home health care? Yes No HAVE YOU BEEN SEEN IN ANY OF OUR CLINICS BEFORE? NO YES When: How did you hear about us?
New Jersey State Disability Claim. Your New Jersey State Disability Benefit Claim. The Standard Benefit Administrators. How To Apply For Benefits
Your New Jersey State Disability Benefit Claim This packet contains the forms that will help us to process your claim for New Jersey State Disability Benefits. Please save a copy of this material for your
DISABILITY BENEFITS. To avoid a possible overpayment of your claim, please inform us if you receive these or other benefits.
Packet Instructions AIG Benefits Solutions DISABILITY BENEFITS This packet contains the forms necessary to apply for Disability benefits. For specific information about your Disability insurance coverage,
For Your Convenience
PLEASE BRING PHOTO ID For Your Convenience U.S. HealthWorks Specializes in Treating On-the-Job Injuries Benefits Of Using U.S. HealthWorks Medical Clinics for Treatment of On-The-Job Injuries Walk-In Care
STATE OF NEW MEXICO WORKERS COMPENSATION ADMINISTRATION. WCA No.: PETITION FOR LUMP SUM PAYMENT RETURN TO WORK
,, and, WCA No.: PETITION FOR LUMP SUM PAYMENT RETURN TO WORK This form should be used for lump sums after return to work for 6 months, earning at least 80% of the pre-injury wage pursuant to 52-5-12(B).
PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:
WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:
Disability claim form
Disability claim form Initial assessment The Anglican Church of Canada In order to ensure confidentiality of personal information, The Pension Office Corporation, Managed Disability Resources, Inc. and
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B
1 Patient Name In order to properly assess your condition, we must understand how much your BACK/LEG (SCIATIC) PAIN has affected your ability to manage everyday activities. For each item below, please
Disability Claim Statement Life Insurance Gardner & White
Disability Claim Statement Life Insurance Gardner & White Please read the following instructions carefully for proper completion of the attached Life Insurance Disability Claim Statement. If this is not
Accident Investigation and Reporting Program Required Forms Instructions and Guidance
Accident Investigation and Reporting Program Required Forms Instructions and Guidance This document contains multiple forms that must be completed for all employee accidents, illnesses or injuries. The
Workers Compensation Program Employee Information Packet
Workers Compensation Program Employee Information Packet 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
Sun Life Insurance and Annuity Company of New York Short Term Disability Claim Packet
Short Term Disability Claim Packet Instructions for the Plan Administrator An initial claim for Short Term Disability benefits should be submitted when a disability absence has actually begun, and it first
NC WORKERS COMPENSATION: BASIC INFORMATION FOR MEDICAL PROVIDERS
NC WORKERS COMPENSATION: BASIC INFORMATION FOR MEDICAL PROVIDERS CURRENT AS OF APRIL 1, 2010 I. INFORMATION SOURCES Where is information available for medical providers treating patients with injuries/conditions
Personal injury claim" does not include a claim for compensatory benefits pursuant to worker s compensation or veterans benefits.
Wisconsin AB 19 (2013) (a) Personal injury claim" means any claim for damages, loss, indemnification, contribution, restitution or other relief, including punitive damages, that is related to bodily injury
SAN JOAQUIN COUNTY Guide to ADA/FEHA Reasonable Accommodation for Employees
SAN JOAQUIN COUNTY Guide to ADA/FEHA Reasonable Accommodation for Employees DEFINITION of DISABILITY UNDER the AMERICANS with DISABILITIES ACT (ADA) and the CALIFORNIA FAIR EMPLOYMENT and HOUSING ACT (FEHA):
Name: Date of Birth: Social Security #: Home # Cell # Address: City: State: Zip: Emergency Contact #: Relationship:
California Back and Pain Specialists 14624 Sherman Way, Suite 309, Van Nuys, CA 91405 1172 Swallow Lane, Simi Valley, CA 93065 101 Hodencamp Road, Suite 103, Thousand Oaks, CA 91360 9201 Sunset Blvd, Suite
Request for Designated Doctor Examination Type (or print in black ink) each item on this form
Texas Department of Insurance Division of Workers Compensation 7551 Metro Center Drive, Suite 100 MS-603 Austin, TX 78744-1645 (512) 804-4380 phone (512) 804-4121 fax Complete, if known: DWC Claim # Carrier
PATIENT INFORMATION. Age: Street address: Email: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.
(Please Print) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Birth date: Age: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Sex: M F Street address:
ACCIDENT PLAN CLAIM FORM
The Lincoln National Life Insurance Company, PO Box 82087, Lincoln, NE 68501-2087 toll free (877) 815-9256 Fax (877) 668-5331 www.lincolnfinancial.com ACCIDENT PLAN CLAIM FORM How To Use this Form to File
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
Business Loan Insurance Plan Disability Insurance Claim Group Policy 51000*
Business Loan Insurance Plan Before submitting a disability claim: Complete and sign the Claimant s Statement for Disability. Sign and complete the Patient Authorization on the Attending Physician s Statement.
WORKERS COMPENSATION FORMS CENTRAL STORES COMMODITY CODES
WORKERS COMPENSATION FORMS CENTRAL STORES COMMODITY CODES Employer s Report of Occupational Injury/ Illness (5020) 7673 Authorization to Release Records (WC10) 7697 Workers Compensation Benefit Election
INSTRUCTIONS WORKER S COMPENSATION CLAIM KIT AEGIS CORPORATION - WORKER S COMPENSATION CLAIM KIT INSTRUCTIONS
CLAIM KIT INSTRUCTIONS SOFTWARE REQUIREMENTS To view, complete, and print this application, you will need Adobe Reader or Adobe Acrobat software. This product is available for free download by visiting
BASIC INFORMATION FOR EMPLOYEES WORKERS' COMPENSATION BENEFITS AND INSTRUCTIONS FOR FILING A CLAIM
BASIC INFORMATION FOR EMPLOYEES WORKERS' COMPENSATION BENEFITS AND INSTRUCTIONS FOR FILING A CLAIM I The Ohio Bureau of Workers' Compensation (BWC) provides employees with the following benefits for work
Short Term Disability Claim Statement
P.O Box 19721, Irvine, CA 92623-9721 EMPLOYER STATEMENT To be completed by the Employer on behalf of the employee. Please print or type. Attach separate sheet if necessary. Short Term Disability Claim
APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS This application package is divided into four sections, as follows: Section I Employer's Statement - to be completed by the employer's authorized representative.
PROCEDURES TO CLAIM SHORT TERM DISABILITY BENEFITS
PROCEDURES TO CLAIM SHORT TERM DISABILITY BENEFITS The Short Term Disability (STD) benefits help you through periods when you are off work due to disability caused by illness or accidental injury outside
United States Department of Labor Employees Compensation Appeals Board DECISION AND ORDER
United States Department of Labor Employees Compensation Appeals Board MARY E. MARSHALL, Appellant and DEPARTMENT OF THE TREASURY, INTERNAL REVENUE SERVICE, Fresno, CA, Employer Appearances: Mary E. Marshall,
PERSONAL INFORMATION
Date: Bruns Chiropractic Clinic EXISTING PATIENT INTAKE FORM (For patients treated within the past 3 years) PERSONAL INFORMATION Name: First MI Last Preferred Name: Gender: M F DOB: / / Age Social Security
Group Journey Injury Insurance
Group Journey Injury Insurance Claim form All relevant sections are to be answered in full. Please print your answers. Zurich does not admit liability by the issue of this form. It is issued to enable
Administrative Procedures Memorandum A4007
Page 1 of 9 Date of Issue May 2015 Original Date of Issue March 2011 Subject WORKPLACE SAFETY AND INSURANCE BOARD (WSIB) CLAIMS References Links Contact Workplace Safety & Insurance Act (Ontario) Human
Advance Health Care Directive Instructions
Advance Health Care Directive Instructions 1) Review the form completely before filling in any section. 2) If possible, name a first agent AND at least one alternative agent (in case something happens
The forms must be completed by a qualified person and signed with their occupational title as per its respective form.
Your ability to work and generate income is your greatest asset. If a disability ever left you unable to work, a combination of increased expenses and loss of income could create financial difficulties.
Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915
Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915 September 10, 2007 Law offices of xxxxxxxxx Santa Monica, CA 90405 REGARDING:
How To Change The Law On Workers Compensation
Overview 2013 Changes to the Tennessee Workers Compensation Act On April 29, 2013 Tennessee Governor Bill Haslam signed into law the Tennessee Workers Compensation Reform Act of 2013 (SB200/HB194). This
MEDICAL ASSESSMENT FORM (FORM B) - GUIDELINES FOR MEDICAL PRACTITIONERS
MEDICAL ASSESSMENT FORM (FORM B) - GUIDELINES FOR MEDICAL PRACTITIONERS InjuriesBoard.ie is an independent statutory body. Our objective is to ensure that people claiming for injuries sustained in an accident,
creditor insurance claim form
Page 8352-05/10 8352-04/01 1 of 5 F I N A N C I A L creditor insurance claim form Instructions for Life Claim What information is required for a Life Claim? completion of the creditor life insurance claim
For use with policies issued by Provident Life and Accident Insurance Company
For use with policies issued by Please mail or fax this form to: The Benefits Center P.O. Box 100158, Columbia, SC 29202-3158 This form must be completed by the Attending Physician and the Employee, and
CLAIM FORM FOR GROUP WAIVER OF PREMIUM BENEFITS
The Company You Keep New York Life Insurance Company Group Membership Association Claims PO Box 30782 Tampa FL 33630-3782 (800) 792-9686 Dear Claimant: We are sorry to learn of your unfortunate illness.
EMPLOYER S STATEMENT
Liberty Life Assurance Company of Boston TO BE COMPLETED BY EMPLOYER Employee s Name, Address & Phone No. EMPLOYER S STATEMENT Mail to: Group Market Disability Claims Liberty Life Assurance Company of
APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company)
APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Member information (Please print or type) Name APTA
(d) Concurrent review means utilization review conducted during an inpatient stay.
9792.6. Utilization Review Standards Definitions For Utilization Review Decisions Issued Prior to July 1, 2013 for Injuries Occurring Prior to January 1, 2013. As used in this Article: The following definitions
TOTAL AND PERMANENT DISABILITY BENEFITS APPLICATION
8403 Colesville Road Silver Spring, MD 20910 Phone: (202) 682-6768 Fax: (202) 962-2939 PLEASE PRINT Instructions 1. 2. 3. The member must complete all questions on the application where indicated or his/her
NEW HAMPSHIRE MOTOR TRANSPORT ASSOCIATION WORKERS COMPENSATION CLAIMS MANUAL TABLE OF CONTENTS
NEW HAMPSHIRE MOTOR TRANSPORT ASSOCIATION WORKERS COMPENSATION CLAIMS MANUAL TABLE OF CONTENTS Chapter 1 Forms Completed by Employer FLING AN EMPLOYER S FIRST REPORT OF INJURY... 2 FILING OF EMPLOYER S
Be submitted in a standard format as per the attached template. Be as clear and concise as possible
Guidelines for Claimant s Practitioner InjuriesBoard.ie is an independent Statutory Body. Our objective is to ensure that people claiming for injuries sustained in an accident have their compensation assessed
City of Los Angeles Disability Insurance Claim Packet Instructions
Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save
SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE
SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE 11:3-29.1 Purpose and scope (a) This subchapter implements the provisions
Self-Insured Injury Reporting PACKET. CareWorksUSA
Self-Insured Injury Reporting PACKET CareWorksUSA IMPORTANT NOTICE FOR WORKPLACE INJURIES In the event of a work-related injury, please see one of the medical providers recommended by your employer listed
THE EMPLOYEE S ROLE: When an Employee is Injured on the Job. Human Resources Management Workers Compensation Program
THE EMPLOYEE S ROLE: When an Employee is Injured on the Job Human Resources Management Workers Compensation Program August 16, 2010 This guidebook gives an overview of the California workers compensation
DISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE)
DISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE) Please answer all questions on the Member s Statement of your Disability Income/Office Overhead
A Guide for Successfully Completing the Group Short-Term Disability Claim Form
A Guide for Successfully Completing the Group Short-Term Disability Claim Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you
PATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
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-! &(";!"./
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
Sun Life Assurance Company of Canada
Short Term Disability Claim Packet Instructions for the Plan Administrator An initial claim for Short Term Disability benefits should be submitted when a disability absence has actually begun, and it first
First Notice of Claim for Illness or Injury
How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents required Section A: Statement of claimant
GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM
GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM A Member of the OCBC Group CLAIM SUBMISSION PROCEDURES Please read carefully before you complete the attached Claim Form. 1. 2. The Great Eastern Life Assurance
BASICS FOR INJURED WORKER: NAVIGATING CALIFORNIA WORKERS COMPENSATION
BASICS FOR INJURED WORKER: NAVIGATING CALIFORNIA WORKERS COMPENSATION Q. What is workers' compensation? A. If you get hurt or sick because of work, your employer is required by law to pay for workers'
Senate Bill No. 2 CHAPTER 673
Senate Bill No. 2 CHAPTER 673 An act to amend Section 6254 of the Government Code, to add Article 3.11 (commencing with Section 1357.20) to Chapter 2.2 of Division 2 of the Health and Safety Code, to add
SOAH DOCKET NO. 453-04-4583.M2 TWCC MR NO. M2-04-0846-01 ' ' ' ' ' ' ' DECISION AND ORDER I. JURISDICTION, NOTICE, AND VENUE
SOAH DOCKET NO. 453-04-4583.M2 TWCC MR NO. M2-04-0846-01 FIRST RIO VALLEY MEDICAL, P.A., Petitioner V. AMERICAN HOME ASSURANCE CO., Respondent BEFORE THE STATE OFFICE OF ADMINISTRATIVE HEARINGS DECISION
Voluntary Disability Benefits
Voluntary Disability Benefits Enclosed you will find a disability packet that will provide information to assist you in filing for disability benefits through The Claremont Colleges Voluntary Disability
RULES FOR FILING A CLAIM AND APPEAL RIGHTS
DIVISION OF TEMPORARY DISABILITY INSURANCE APPLICATION FOR FAMILY LEAVE INSURANCE BENEFITS (FL-1) DETACH THIS PAGE AND KEEP FOR YOUR RECORDS RULES FOR FILING A CLAIM AND APPEAL RIGHTS 1. It is your responsibility
SI 2047-643383 1 of 6 (12/04)
Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save
Long Term Disability Income Benefit. Employee s Guide
Long Term Disability Income Benefit Employee s Guide Long Term Disability Income Benefits This guide explains how to apply for Long Term Disability benefits. It contains the form you must complete to notify
For use with policies issued by Provident Life and Accident Insurance Company
For use with policies issued by Please mail or fax this form to: Chattanooga Benefits Center P.O. Box 12030 Chattanooga, TN 37401-3030 Toll free: 800.633.7479 Fax: 423.755.3009 or 800.494.4516 This form
Disability Claim Form Initial Request
GROUP INSURANCE Disability Claim Form A partner you can trust. www.inalco.com According to your region, please submit the completed form to: Quebec All Other Provinces PO Box 790, Station B 522 University
Creditor Disability Claim Application Kit
Life and Health Claims Dept. Creditor Disability Claim Application Kit The Application Kit contains: an instruction sheet plus forms that need to be completed in order to apply for disability benefits;