Workman's Compensation Information Form - Family Practice Associates

Workman's Compensation Form

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PATIENT INFORMATION

Date of Injury/Accident

Patient Name

First

Middle

Last

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Date of Birth

Social Security #

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Home Phone

Cell Phone

Work Phone

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Employer

HR Contact Person

Phone

INSURANCE INFORMATION

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Insured

Insurance Company

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Claim Adjuster

Phone

Claim Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Law Firm

Attorney

Law Firm's Address

Address Line 1

Address Line 2

City

State

Zip Code

I understand that Family Practice Associates has a conflict of interest with the law firm of Roeberg Moore & Friedman. If I choose this firm, I must find another physician outside of Family Practice Associates to manage my workman’s compensation injuries.

If I choose any of these attorneys, I must find another physician outside of Family Practice Associates to manage my workman’s compensation injuries.

I agree

AUTHORIZATION TO RELEASE INFORMATION AND TO PAY BENEFITS DIRECTLY TO FAMIY PRACTICE ASSOCIATES, P.A.

I hereby authorize the release of my records from the files of Family Practice Associates:

Checkboxes

concerning only my examinations, treatments and physical condition related to my accident or injury.
concerning my examinations, treatment and physical condition (entire record).

Assignment and Release: I hereby authorize my insurance benefits be paid directly to Family Practice Associates, P.A. for any and all medical /surgical procedures performed or services rendered in this matter. I am financially responsible for non-covered services.

Print Name

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Guardian if patient is a minor

Signature

Date

Electronically Signed

I Agree

I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

SETTLEMENT DISBURSEMENT AUTHORIZATION

I, the undersigned, hereby authorize my law firm to utilize funds from my settlement for the payment of any outstanding medical claims resulting from my accident.

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Attorney's Name

Phone

Account Number

Print Name

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Patient / Guardian Signature:

Electronically Signed

I Agree

I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

Date

Guardian if patient is a minor

ATTORNEY ATTESTATION

This statement will serve as confirmation that the balance de Family Practice Associates, P.A. will be protected in the event of settlement of this claim.

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Attorney Signature

Electronically Signed

I Agree

I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

Date

LETTER OF AGREEMENT BETWEEN FAMILY PRACTICE ASSOCIATES (FPA) AND WORKER’S COMPENSATION CLAIMANTS / PATIENTS

I understand that in the event my Worker’s Compensation Insurance DOES NOT cover the fees for services provided by Family Practice Associates, P.A., I am responsible for the balance.

I agree

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Signature

Gaurdian if patient is a minor

Printed Name

Date

Electronically Signed

I Agree

I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

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