NY•CONN Orthopaedic &
Workers’ Compensation Claim
Patient Name: Date of Birth: / / Social Security No.
Employer Name: Telephone No. ( )
Employer Street Address:
Date of Injury: Time of Injury: When did employer file with carrier? In what City & State did the original injury occur?
/ / ______AM ______PM / / City: ______________ State: ______________
Please describe how and where original injury occurred: ___________________________________________________________________________
Are you now, or have you in the past, been involved in active litigation or had a Did any other physician and/or hospital see you prior to this
settlement and/or closure involving this injury? Yes No appointment? (List all that apply)
If yes, please explain: ____________________________________________ Name: ______________________________________
__________________________________________________ Address: ____________________________________
Telephone No. ( ) _________________________
Insurance Carrier: _________________________________________ Case Manager Contact: __________________________
Address: ________________________________________________ Address: _______________________________________
________________________________________________ Phone #: ( )________________________________
Workers Compensation Board #: ____________________________ Fax #: ( )___________________________________
Carrier Case #: __________________________________________
ASSIGNMENT OF BENEFITS
I hereby authorize NYCONN Orthopaedics & Rehabilitation Specialists to release any/all medical information on this patient to Workers’
If for any reason this claim is rejected by Workers’ Compensation, I am responsible for the charges incurred. I agree to pay NYCONN Orthopaedics &
Rehabilitation Specialists their usual and customary fees for services rendered to me.
I hereby authorize NYCONN Orthopaedics & Rehabilitation Specialists to file a claim in my behalf with my Workers’ Compensation Carrier.
A photocopy may serve the same capacity as an original. ____________________________________________
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