Complex Worker's Compensation Appointment Request

Complex Worker's Compensation Appointment Request

Complete this form to request an appointment and provide necessary details for processing.
Patient and Claim Information
Submission Instructions: Email questionnaire and records less than 45 pages to workcomp@orlandoortho.com. Please mail records exceeding 45 pages with no fax cover sheets, DWC-25, or physical therapy notes to: Orlando Orthopaedic Center, 25 West Crystal Lake Street, Suite 200, Orlando, FL 32806, Attn: Complex Work Comp.
Media Restrictions: Films must be in DICOM format on CD or USB. No cloud-based portals or QR codes accepted. Records must be in single-sided paper format. Records not accepted on cloud-based portals, CD, or USB.
Date

MonthDayYear
Date
Type of Request
Patient Name
DOB

MonthDayYear
Date
Gender
SS#
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Claim ID
Preferred Language
Adjuster/Case Manager to Provide Translator
Claim #
Out of State or FL Jurisdiction W/C Claim?
Federal W/C Claim?
Date of Injury

MonthDayYear
Date
Authorized Body Part(s)
How Was the Patient Injured?
Employer, Insurance, and Prior Care
Employer's Name
Employer's Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Previous Treatment or Evaluation to Body Part(s)?
Facility
Specialists Seen
Date(s) of Prior Surgeries to Body Part(s)

MonthDayYear
Date
Images Taken
Requested Physician
Requested Location
Preferred TPA For DME Diagnosis Therapy
Adjuster, Billing, and Case Manager Contacts
Adjuster Name
Network (If Any)
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Billing Phone
Please enter a valid phone number.Format: (000) 000-0000.
Billing Fax
Please enter a valid phone number.Format: (000) 000-0000.
Adjuster Phone
Please enter a valid phone number.Format: (000) 000-0000.
Adjuster Fax
Please enter a valid phone number.Format: (000) 000-0000.
Adjuster Email
example@example.com
Case Manager Name
Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Fax
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Email
example@example.com
Should be Empty:

Complex Worker's Compensation Appointment Request

Patient and Claim Information

Employer, Insurance, and Prior Care

Adjuster, Billing, and Case Manager Contacts