CLIENT APPLICATION. Client Phone: (H) (C) Address City State Zip. Birth Date: SSN: Referred by: /Webfile Username WebFile Pin Number

Transcription

1 CLIENT APPLICATION PERSONAL INFORMATION: Today s Date Client Phone: (H) (C) Address City State Zip Birth Date: SSN: Referred by: /Webfile Username WebFile Pin Number Highest Level of Education Completed: Marital Status: Spouse s Name: Emergency Contact: Phone: Military Veteran: YES / NO Branch of Service Rank: Have you ever been convicted of a felony? Y / N Highest Level of Education: Special skills or Certifications: EMPLOYER AT TIME OF INJURY: Address Job Title/Occupation How Long Weekly Wage $ Do you have any other employment? If so, where: PREVIOUS EMPLOYMENT

2 ACCIDENT INFORMATION Date of Accident Time Place Person Notice was Given to When Brief Description of how the injury occurred: Was there any witnesses? If so, please list: Please list all body part affected: Present Complaints What is your biggest concern? Have you sued or are you planning to sue any third party (not your employer) regarding this accident? If so, whom? MEDICAL INFORMATION Have you any prior injury to the same part(s) of your body? Any other diagnosed medical conditions: If yes, please give description and date of injury:

3 Do you have any personal health insurance? Provider ID # Group # ** Please provide a copy of your insurance card at the time of your appointment. ** Do you have Medicare/Medicaid insurance coverage? Have you applied for or are you receiving Social Security Disability Benefits? CLAIM AND BENEFIT INFORMATION Are you currently receiving any workers compensation benefits? If so, how much per week? Are you currently under an award? JCN: Do you have Doctor s Disability Slips excusing you from work? What work restrictions are you currently under? INSURANCE INFORMATION Workers Compensation Insurance Carrier: Address: Phone: Adjuster: Claim Number: NAME AND ADDRESS OF PRIMARY CARE PHYSICIAN/FAMILY DOCTOR: Doctor Address: Phone: Date of Last Visit: LIST ALL DOCTORS WHO HAVE TREATED YOU FOR THIS ACCIDENT (1) Doctor Address: (2) Doctor Address:

4 (3) Doctor Address: Have you had surgery as a result of this accident? If so, when? Has a doctor given you a functional capacity evaluation (FCE) or a permanent partial disability rating? If yes, what is your rating? Body part(s): LIST ALL HOSPITALS WHERE YOU HAVE BEEN TREATED FOR THIS ACCIDENT (4) Hospital: Address: Date Treated: Body Part(s): Reason for Hospital Visit: (5) Hospital: Address: Date Treated: Body Part(s): Reason for Hospital Visit: Additional Notes:

5 Dangers We ve found that these are the common obstacles and issues people like you are facing. Circle all that are relevant to you, and add others if needed. Fear of losing job Don t know another trade No income Marital stress Need medical treatment & no regular health insurance, money for gas or co-pays Losing house, car Claims adjuster difficult to deal with Vocational rehab difficult to deal with Financial difficulties Nurse case manager difficult Fear of unknown Getting put into a job you hate Concern about future job/income/career Concern about future health Don t understand WC process Depression Dislike current medical treatment Prescription drug addiction Lost job Non WC medical issues Unsure if should settle Don t know what to do Don t know obligations Hostile or difficult work environment Wants As well as obstacles, you have many opportunities you d like to be freed up to focus on. Circle those that apply to you, and feel free to add others that fit. To explore new job opportunities Opportunity to go to school Freedom from the WC system An attorney to look out for your best interest To understand process All details taken care of by someone else WC benefits secured Manage own employment situation & career Get out of debt New start Keep current employment To file for Social Security Disability Get a weekly check Manage own medical care To not be dependent on a weekly WC check To focus on health, not WC issues The maximum benefits to which you re entitled Proper medical treatment Specific medical treatment Maximum financial benefits Lump sum settlement Provide for family better To never return to the same employer, to any job and/or retire Strengths You have many talents, capabilities, and skills that you d like to reinforce and maximize. Circle those that best represent you and add others if needed. Positive attitude Many work trades/ skills If advised, will try difficult things Have current job prospect Trusting Not afraid to go to court Friend and family support Not afraid to have deposition taken Good plan on what to do with career & future job opportunities tedious WC requirements of looking for a job Ability to actively gather information unmet expectations and/or want change Good money manager stress Strongly motivated Have options for continued medical care difficult adjusters, doctors, NCMs & VOC Good plan on what to do with lump sum of money hostile/ difficult work environment Can be patient to get the most benefits Can adapt to situations