WORKER'S COMPENSATION INTAKE FORM

Accident Information

Patient First Name

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Patient Last Name

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Type of Injury:

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Date of Accident:

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How did the accident occur?

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Where did the accident take place?

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Insurance Information

Third Party Insurance Company:

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Address:

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Policy Number:

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Claim Number:

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Insured Name:

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Agent / Contact:

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Phone:

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I authorized payment of medical benefits to Jefferson Orthopedic Clinic for services rendered. Should my health insurance company or third party not pay charges associated with the above Accident, I understand that I will be financially responsible for payment on this account. I hereby Authorize Jefferson Orthopedic Clinic to release all information regarding my medical care to the above third party for all charges related to this accident date.

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Date:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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