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PAIN SPECIALISTS OF TEXAS WORKERS COMPENSATION INFORMATION PATIENT INFORMATION: NAME_______________________________ BIRTHDATE________________ SEX F M MARITAL STATUS____________ ADDRESS______________________________ CITY___________________ STATE______ ZIP CODE_____________________ HOME PHONE________________________ CELL PHONE_____________________ WORK PHONE_________________________ REFERRING DOCTOR________________________ PHONE____________________ REASON_____________________________ EMPLOYER INFORMATION: EMPLOYER NAME_____________________________________ PATIENT’S OCCUPATION_______________________________ ADDRESS________________________________ CITY___________________STATE______ ZIP CODE_______________________ EMPLOYER PHONE______________________________ EMPLOYER CONTACT FOR INJURY_____________________________ WORKER COMPENSATION CARRIER: COMPENSATION CARRIER_______________________________________ CLAIM NUMBER_______________________________ CARRIER ADDRESS_________________________ CITY_________________STATE_____ ZIP CODE___________________ CARRIER PHONE_______________________ ADJUSTOR’S NAME________________________________ ADJ EXT_________ INJURY INFORMATION: DATE OF INJURY________________ TIME OF DAY OCCURRED____________ PLACE OF INJURY__________________________ PERSON YOU REPORTED INJURY TO________________________ CHIEF COMPLAINT____________________________________ LIST ALL PHYSICIANS AND THEIR PHONE NUMBERS WHO YOU HAVE SEEN FOR THIS COMPLAINT_____________________ __________________________________________________________________________________________________________________ IF X-RAYS OR OTHER TESTING DONE, PLEASE LIST TYPE OF TESTS AND DIAGNOSIS FOUND___________________________ __________________________________________________________________________________________________________________ LIST ALL DIAGNOSES AND DATES OF OTHER WORKERS COMPENSATION INJURIES____________________________________ __________________________________________________________________________________________________________________ GIVE FULL DESCRIPTION HOW ACCIDENT HAPPENED?______________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ HOW MUCH TIME LOST FROM WORK?_______________________ ARE YOU CURRENTLY WORKING? Y N EMERGENCY CONTACT IN CASE OF EMERGENCY NOTIFIY_______________________________________RELATIONSHIP TO PT_____________________ HOME PHONE__________________________ WORK PHONE_________________________ CELL PHONE______________________ ASSIGNMENT AND RELEASE: I HEREBY AUTHORIZE ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME TO BE PAID DIRECTLY TO PAIN SPECIALISTS OF TEXAS. I UNDERSTAND THAT IF IT IS DETERMINED THAT THE VISITS RENDERED ARE NOT RELATED TO MY WORKERS COMPENSATION INJURY THAT I WILL BE RESPONSIBLE FOR ALL CHARGES INCURRED. I ALSO AUTHORIZE PAIN SPECIALISTS OF TEXAS, TO RELEASE INFORMATION TO SECURE PAYMENTS ON MY BEHALF. I AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE FORMS. SIGNATURE OF PATIENT/AUTHORIZED PARTY______________________________________________DATE____/____/________ |
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