drsharongilbertdc.com - Workers Comp

WORKER COMPENSATION INFORMATION

Información sobre la compensación del trabajador
PATIENT INFORMATION / Información del paciente
Date / Fecha

MonthDayYear
Date
Name / Nombre

First / NombreLast / Apellido
Soc. Sec # / Seguro Social
Home Phone / Tel. Casa
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone / Tel. Trabajo
Please enter a valid phone number.Format: (000) 000-0000.
Address / Dirección

Address / Dirección

Street Address Line 2

City / CiudadState / Estado

Zip Code / Código postal
MF
Age / Edad
Birthdate / Fecha de nacimiento

MonthDayYear
Date
Single / Soltero(a)Married / Casado(a)
Occupation / Ocupación
Number of years doing current job / Cuántos años en este trabajo
In case of emergency who should be notified? / En caso de emergencia, a quién notificar?
Relationship / Relación
Phone / Teléfono
Please enter a valid phone number.Format: (000) 000-0000.
INJURY INFORMATION / Información sobre la lastimadura
Date of injury / Fecha del accidente/lastimadura

MonthDayYear
Date
Time of injury / Tiempo del accidente/lastimadura

Hour Minutes

AM/PM Option
Occupation when injured / Ocupación cuando se accidentó
Activity being performed at the time of the injury / Actividad desempeñada al tiempo del accidente/lastimadura
Yes / SíNo
If yes, by whom? / Si es así, ¿por quién?
To whom was the injury reported? / ¿A quién fue reportado el accidente?
Date injury was reported / Fecha y hora que fue reportado el accidente

MonthDayYear
Date
Yes / SíNo
From / Desde

MonthDayYear
Date
Thru / Hasta

MonthDayYear
Date
Describe where and how the accident or cause of disability occurred / Describa la causa de cómo y dónde ocurrió el accidente o la inhabilidad
EMPLOYER INFORMATION / Información del empleador
Employer’s name / Nombre del empleador
Phone / Teléfono
Please enter a valid phone number.Format: (000) 000-0000.
Employer’s address / Dirección del empleador

Dirección

Street Address Line 2

City / CiudadState / Estado

Zip / Código postal
Who should be contacted regarding the injury? / ¿A quién se debe notificar sobre este accidente?
Phone / Teléfono
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE INFORMATION / Información sobre la aseguranza
Worker’s compensation insurance carrier / Aseguranza del portador para la compensación al trabajador
Phone / Teléfono
Please enter a valid phone number.Format: (000) 000-0000.
Address / Dirección

Address / Dirección

Street Address Line 2

City / CiudadState / Estado

Zip / Código postal
Claim # / Número de demanda
Adjuster’s name / Nombre del agente
Phone / Teléfono
Please enter a valid phone number.Format: (000) 000-0000.
PAYMENT INFORMATION / Información del pago
I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.

Yo entiendo claramente y estoy de acuerdo que todos los servicios que se me hagan sean cobrados directamente a mí; y personalmente me hago responsable por el pago. También entiendo que si yo paro o suspendo mi tratamiento y cuidado, los honorarios por los servicios profesionales rendidos a mi persona serán inmediatamente pagados.
Patient’s Signature / Firma del paciente

Clear
Date / Fecha

MonthDayYear
Date

Patient Authorization for Use & Disclosure of Protected Health Information
1. I,   Patient Name   hereby authorize   Authorized Person / Entity        to use and/or disclose to In-Line Chiropractic Care the following specific protected health information:
All Medical Record   Radiology Reports
DOB   DOI
2. I understand that this authorization is valid until   Date   or until further notice.
3. I understand that the purpose of use or disclosure of the information I am granting is for proper diagnosis and accurate treatment.
4. I expressly acknowledge that this authorization is voluntary.
5. The following is/are other criteria or limitations that I make regarding this authorization:Other Criteria or Limitations
6. I understand that this office will not receive financial or in-kind compensation in exchange for using or disclosing the health information described above.
7. I understand that I may revoke this authorization in writing at any time in accordance with the attached authorization revocation procedure. I also understand that the revocation of this authorization will not affect disclosures occurring prior to the execution of any revocation.
8. I understand that the information used or disclosed pursuant to this authorization may be subject to being disclosed again by the recipient and that this information will no longer be protected by federal privacy regulations.
9. I understand that my health care and payment for my healthcare will not be affected if I do not sign this form.
10. I understand that I may see and copy the information described in this form, if I ask for it, and that I will get a copy of this form after I sign it.
11. This form was completely filled in before I signed it. I certify that all of my questions were answered to my satisfaction and that I understand this authorization form and all of its contents.
12. This authorization is valid as of   Date   , the date I have signed below.
Name of Individual (Printed):
Signature of Individual:

Clear
Signature of Legal Representative:

Clear
Relationship:
Witness: