Patient Registration

Work Comp Claim Information
Workman's Compensation Insurance:
Employer at time of injury:*
Occupation:*
Date of Injury:*

MonthDayYear
Date
Describe Injury:*
What body part/s are injured: Please list all and include which side:
Have you injured this body part/s before

yesno
If yes, please describe:
Have you had an MRI, MRA or CT? If so where?*

ClearviewRayusProvidenceLegacySalem FacilityNo MRI,MRA or CT yetOther
Adjuster Name:
Adjuster Phone Number:
Please enter a valid phone number.
Adjuster Email:
example@example.com
Claim #:
Referring Physician or Location:
Please list treating physicians, therapists and treatment to date:*

Family History
Any of your immediate family members have or had any of the following?*

Anesthesia ComplicationCancerDiabetesHigh Blood PressureOther:None of the above
Please list relation with each complication checked:

Consent to use or disclose Medical Information
I authorize Occupational Orthopedics, LLC to use and disclose of my health and medical information for the following purposes:
- Treatment: Use by our providers, staff, coordinating care with other medical providers, work compensation carrier and disability insurance companies
- Payment: Including authorization, scheduling, billing, payment, review for medical necessity, justification of charges, precertification and prior authorizations
- Healthcare Operation: Includes the usual administrative and business functions of our office
I understand that I have the right to revoke or restrict this consent provided that I do so in writing, except to the extent that Occupational Orthopedics, LLC has already used or disclosed the information in reliance to this consent.
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Patient Name:*

First NameLast Name
Signature*

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Work Comp Claim Information