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WORKERS COMPENSATION INTAKE FORM Greenway Chiropractic Clinic Dr. R. W. Braunstein 8070 S.W. Hall Blvd. Suite 100 Beaverton, Oregon 97008 CONFIDENTIAL PATIENT INFORMATION Name: Today's Date: / / Address:

How to fill out workers compensation intake form

How to fill out a workers compensation intake form:

Start by including your personal information:

1. Provide your full name, address, and contact information.
2. Fill out your date of birth and social security number.
3. Include your job title and current employer's information.

Provide details about the injury:

1. Describe how the injury occurred, including the date, time, and location.
2. Explain the specific body part(s) affected and the nature of the injury.
3. Indicate if you sought immediate medical attention or if there were any witnesses.

Include information about your employment and insurance:

1. State your employment start date and your current job responsibilities.
2. List any previous workers compensation claims filed or any prior injuries.
3. Provide details about your insurance coverage, including the policy number.

Disclose your medical treatment:

1. Provide the names and contact information of any healthcare providers you have seen.
2. Describe the medical treatment received, including medications prescribed.
3. Attach copies of any medical records, bills, or reports related to the injury.

Answer the additional questions:

1. Respond to any supplementary questions related to the accident or injury.
2. Provide any other relevant information that may support your claim.

Who needs workers compensation intake form?

Workers who have suffered a work-related injury or illness are required to submit a workers compensation intake form. This includes:

1. Employees who sustain physical injuries while on the job, such as fractures, sprains, or strains.
2. Workers who develop occupational diseases as a result of their work environment, like mesothelioma or repetitive strain injuries.
3. Individuals who experience mental health conditions due to work-related stress or traumatic events.

It is essential for employees to fill out the workers compensation intake form accurately and promptly to ensure that their claims are processed efficiently and that they receive the necessary benefits and medical treatment.

For pdfFiller’s FAQs

What is workers compensation intake form?

Workers compensation intake form is a document that must be completed by an employee who has been injured on the job to report the details of the incident.

Who is required to file workers compensation intake form?

Any employee who has suffered a work-related injury or illness is required to file a workers compensation intake form.

How to fill out workers compensation intake form?

To fill out a workers compensation intake form, the employee must provide details about the injury, including when and where it occurred, as well as any medical treatment received.

What is the purpose of workers compensation intake form?

The purpose of the workers compensation intake form is to document and report work-related injuries or illnesses in order to start the compensation process.

What information must be reported on workers compensation intake form?

The workers compensation intake form must include details such as the employee's name, date of injury, description of the incident, and any medical treatment received.

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