NYCONN Orthopaedic Rehabilitation Specialists Workers

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					                                                    NY•CONN Orthopaedic &
                                                    Rehabilitation Specialists

                                                  Workers’ Compensation Claim


                                                      PATIENT INFORMATION
Patient Name:                                                                 Date of Birth:   /        /          Social Security No.

                                                 EMPLOYER’S INFORMATION
Employer Name:                                                                                         Telephone No. (       )

Employer Street Address:

                                                       INJURY INFORMATION
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 INFORMATION
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’
Compensations Carrier.

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.
                                                                        ___________________________________________
                                                                                               (Signature)

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.                ____________________________________________
                                                                                                (Signature)



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