Orthopedic Surgical Consultants, P.A.

Complete only if due to a Worker's Comp, Auto, or Liability Related Injury

 

Name:__________________________________________ Acct.#:________________   Date: _________
                       First                            Middle                      Last    

WORK COMP INJURY
Date of Injury:   ______________________________________
Area of body to be treated (Please indicate left/right side): _____________________________________
Name of Insurance Company:  _________________________________________    Phone: ____________________
Address:  _____________________________________ City:  _____________________ State: ______ Zip: ________
Claim Number:  _______________________________________

Have you been treated for a similar condition?   YES      NO
If Yes, When:  __________________________ Treating Physician:  _______________________________
Attorney Name: _______________________________________ Phone:  __________________________
If your claim is work comp., list employer name at time of injury:  _______________________________________
Employer contact person:  _______________________________ Phone:  __________________________
Is your worker's compensation insurance a managed care policy?:     YES        NO
     

AUTO ACCIDENT INJURY
Date of Injury:   ______________________________________
Area of body to be treated (Please indicate left/right side): _________________________________________
Auto  Insurance Company:  ___________________________________   Phone: ______________________
Address:  _____________________________ City:  _____________________ State: ______ Zip: ________
Claim /Policy Number:  _________________________________

Have you been treated for a similar condition?   YES      NO
If Yes, When:  __________________________ Treating Physician:  ______________________________
   

LIABILITY INJURY
   
Date of Injury:   ______________________________________
Area of body to be treated (Please indicate left/right side): _________________________________________
Location of injury (Store, House, Hotel, Casino, Other): ________________________________________
Address:  ______________________________ City:  _____________________ State: ______ Zip: _________
Insurance Company:  ____________________________________________        Phone:  _________________
Address:  ______________________________ City:  _____________________ State: ______ Zip: _________
Claim /Policy Number:  _________________________________

Have you been treated for a similar condition?   YES      NO
If Yes, When:  __________________________ Treating Physician:  ______________________________
Attorney Name: _______________________________________ Phone:  _________________________
     
Patient will be billed if information is not received by fax, mail or phone within 3 business days.  We cannot billprivate insurance without a denial from Work comp, Auto or Liability Insurance.  Please list private insurance information on patient demographic form even if related to one of the above injuries.

 
Signature: ___________________________________________  Date:  ____________________