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Worker's Compensation Patient Informational

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					          Workers Compensation SOS Patient Informational

        Please be aware of Workers Compensation Carriers & Dates of Injuries:
 We rely on you, our patient, to supply us with the most accurate information
possible. Wrong and/or lacking information could result in not being able to expedite
requests and billing information needed by your carrier to continue your ability to
receive compensation benefits.

After today’s visit, your Workers Compensation Carrier and the Workers Compensation
Board will be sent a C4 form for services rendered with a complete copy of today’s
exam along with any requests for additional testing or surgery needed recommended by
your Physician. PLEASE NOTE: This process could take up to 5 – 10 business days.

Upon receiving that information, your carrier has up to 30 days to respond to any
requests made. PLEASE NOTE: If you are working with a Workers Compensation Nurse
Case Manager, please make us aware of their contact information as they could greatly
expedite requests and testing that may be needed for your treatment.

Please understand that it is our intention to help you get back to work as quickly and
safely as possible. We know that the Workers Compensation process can be a slow
moving process and with your cooperation, we can work together to make this process
as quick and simple as possible.

Please complete the enclosed forms and return to a patient representative.
A.) Disclosure of health information (HIPAA -1) : This allows SOS to speak to case
    managers, employers and insurance companies directly to insure the most efficient
    care possible.
B.) SOS W/Comp Registration Form: This form is used by our clerical and billing staff at
    registration to clarify the most accurate information regarding your work related
    injury as well as verify what daily duties you currently perform at your job.

				
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posted:10/19/2011
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