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Workers legal name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Patient Phone*
MaleFemale
Language preference
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claim no if known
Date of original injury

MonthDayYear
Date
Occupation
Last date worked

MonthDayYear
Date
Employer at time of original injury name and street address (If known)*
Employers Phone
Workers compensation insurers name
Describe current injury
Have you injured this same body part before?

YesNo
If yes when
By signing this form, I authorize health care providers and other custodians of claim records to release relevant medical records to the workers' compensation insurer, self-insured employer, claim administrator, and the Oregon Depoartment of Consumer and Bsuiness Services. Relevant medical records include records of prior treatment for the same condiotions, or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164-512(O))

I certify that the above information is true to the best of my knowledge and belief.
Signature*

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Date*

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Date
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