New Patient Intake Form - Workers Comp Injury

Patient Intake Form - Workers Comp Injury
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Current Height*
Your Current Weight (lbs)*
What is your dominant hand/side?*

RightLeft
Are you currently on any medications?/please list your medication history over the last year (Name of medication & Dosage if you remember)*
Please list your previous health history - i.e. do you currently have or have you ever been diagnosed with any health conditions? Have you had any prior injuries or accidents other than the one you are being treated for today?*
Date of Injury*

MonthDayYear
Date
If you have your case Carrier and Claim Number, please enter that information below.
Are you currently working?*

YesNo
If you are working, are you working with restrictions?
If you're not working, when was the last date you worked?
Employer Name (at the Time of Injury)*
Your Job Title (at the Time of Injury)*
Position Employment Status*
How long have you worked for the company?*
What were your job duties, including weights you had to lift, were they physical duties? Please list and include exact lbs - 50, 75lb, etc.*
Did you have any physical restrictions prior to the Injury?*

YesNo
If yes to physical restrictions prior - please put restrictions below
What were the job hours?*
How many hours did you work per day?*
Please explain what happened on the date of injury/how you got hurt*
Which areas of the body did you injure?*
Please describe the current pain you are feeling*
Please list what daily activities/activities at home that are now limited because of your injury*
Please list any and all treatments you had for this Injury. Please also include any of the doctors or hospitals you were treated at. *
Have you ever injured yourself before this accident? If yes, please put the date of injury and what treatments you had received.*

Assignment of Benefits
ASSIGNMENT OF BENEFITS & AUTHORIZATION FOR DIRECT PAYMENT

I hereby assign all applicable medical and/or insurance benefits to CarePath Injury Centers for services rendered in connection with my Workers’ Compensation (WC) / Motor Vehicle Accident (MVA) claim. I authorize direct payment to CarePath Injury Centers from my insurance carrier or any responsible third party payer.

I understand that this assignment of benefits does not relieve me of financial responsibility for any charges not covered by my insurance, including but not limited to co-payments, deductibles, denied claims, or limitations on coverage. I agree to cooperate with CarePath Injury Centers & my legal teams in any necessary efforts to secure payment, including but not limited to providing additional information, signing required documents, or pursuing appeals for denied claims.

Release of Information:
I authorize CarePath Injury Centers to release any medical records, reports, or other necessary information to my insurance carrier, legal representatives, and other involved parties for the purpose of claim processing, billing, and reimbursement.

Lien & Third-Party Reimbursement Agreement (if applicable):
I understand that if my claim is subject to litigation or settlement, I authorize my attorney to make payment directly to CarePath Injury Centers for any outstanding medical bills from settlement proceeds. I agree to inform CarePath Injury Centers of any changes regarding my legal representation, insurance coverage, or claim status.

Acknowledgment & Signature:
By signing below, I confirm that I have read and understood this Assignment of Benefits.
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Patient Signature*

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Records Release
I hearby give CarePath Injury Centers of Pennsylvania permission to request and receive medical, imaging, and other associated records from other institutions that I have visited, been seen or been a patient at for my accident/injury. They may request records on my behalf and receive them to utilize for my care plan with them moving forward.
Today's Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Signature*

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Patient Intake Form - Workers Comp Injury

Assignment of Benefits

Records Release