Workers' Comp. Info

Workers' Compensation Claim Info

This document collects the information required for processing Worker's Compensation claims related to medical treatment at this establishment.
Claimant Info

Information about the Patient and their Workers' Compensation claim.
File No.
Claim Number
Patient's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Adjuster Info

Who is your claims adjuster?
Adjuster's Name

First NameLast Name
Adjuster's Phone
Format: (000) 000-0000.
Adjuster's Email
example@example.com
Insurance Company
Claim Details

Tell us what happened.
Are the injuries caused by accident?
Details of the accident
Please be specific about the details.
Are the injuries related to your job?
Details of the injury
How did you get hurt? Please be specific about the details.
Medical Data

Provide info about your diagnosis, condition and treatment.
Chief Complaints
What is your primary concern? What hurts? What is your condition?
Date symptoms presented

MonthDayYear
Date
Please provide details of the past treatment
What treatments have you received in the past for these conditions?
Medical Diagnosis
What is your formal diagnosis?
Physician Info

Who is responsible for your care? Who prescribed this treatment?
Physician Name

First NameLast Name
Business Name
Physician Phone Number
Format: (000) 000-0000.
Physician Email
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member/Patient Signature
Date Signed

MonthDayYear
Date
HIPAA Release Authorization

AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION
I authorize AdamLMT.com - Healing Hands Massage Therapy to release the following PHI: Treatment Notes and Records, Invoices and Billing information to {adjustersName60} and {physicianName} as identified above by on this application. I understand that this PHI will be used for the purpose of coordinating my care and for satisfying service claims made by AdamLMT.com - Healing Hands Massage Therapy.

I understand the following:

1. I authorize the use or disclosure of Protected Health Information as described
above for the purpose indicated for up to 1 year from the date of my most recent service or until I provide a written revocation of authorization.

2. I have the right to revoke this authorization. To do so I understand I must submit
my revocation in writing to AdamLMT.com - Healing Hands Massage Therapy, 3270 Suntree Blvd. Suite 1130, Melbourne, Fl. 32940. The revocation will prevent further disclosure of my health information by AdamLMT.com - Healing Hands Massage Therapy from the date of receipt. I also understand that a written revocation is not effective with respect to actions AdamLMT.com - Healing Hands Massage Therapy took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage.

3. I am signing this authorization voluntarily and understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not sign this HIPAA Authorization Form.

4. If the party specified in pages 2 & 4 is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR §160.103, the disclosed health information may no longer be protected by federal and state privacy regulations.

5. I have a right to receive a copy of this HIPAA Authorization Form.
Member/Patient Signature

Authorized
Date Signed

MonthDayYear
Date
Should be Empty:

Workers' Compensation Claim Info

Claimant Info

Adjuster Info

Claim Details

Medical Data

Physician Info

HIPAA Release Authorization