Get the free Work Injury Referral Form

Date: Taken by: Work Injury Referral Form o PCE (1045M) o 1-Day o 2-day o Hand/UE PCE (1045M) o Baseline/Job-Specific/Test to Tolerance o Work Conditioning (97530, 97110, 97537) o Work Hardening (1000M-1018M)

How to fill out work injury referral form

How to fill out work injury referral form:

1. First, gather all necessary information. This includes the injured person's name, contact information, and job title. It's also important to know the date and time of the injury, as well as a detailed description of what happened.
2. Next, provide information about the employer. This includes the company's name, address, and contact information. It's essential to accurately state the nature of the employer's business and the injured person's position within the company.
3. Fill in the details about the medical provider. This includes the healthcare professional's name, address, and contact information. It's crucial to provide accurate information to ensure proper communication and coordination of care.
4. Describe the injury in detail. Be as specific as possible about the nature of the injury, the affected body part(s), and any immediate symptoms. If there were any witnesses to the incident, provide their contact information as well.
5. Provide insurance information. This includes the workers' compensation insurance carrier's name, address, and policy number. It's important to have this information readily available to ensure a smooth claims process.
6. Sign and date the form. In most cases, both the injured person and their supervisor or employer will need to sign the form to verify the accuracy of the information provided. Ensure that all required signatures are obtained before submitting the form.

Who needs work injury referral form?

Work injury referral forms are typically needed in situations where an employee has suffered a work-related injury. These forms are required by employers, healthcare providers, and insurance companies to initiate the workers' compensation claims process. Specifically, those who need work injury referral forms include:

1. Injured employees who seek medical attention for their work-related injuries.
2. Employers who are responsible for reporting and documenting work-related injuries.
3. Medical providers who treat injured employees and need to communicate with the employer and insurance carrier regarding the treatment and prognosis.

Ultimately, the work injury referral form is important for all parties involved to ensure that proper care is provided to the injured employee and that the workers' compensation process is initiated appropriately.

For pdfFiller’s FAQs

What is work injury referral form?

The work injury referral form is a document used to report workplace injuries to the appropriate authorities.

Who is required to file work injury referral form?

Employers are required to file the work injury referral form when an employee is injured on the job.

How to fill out work injury referral form?

The work injury referral form is typically filled out with details of the injury, including the date, time, and location of the incident, as well as information about the injured employee.

What is the purpose of work injury referral form?

The purpose of the work injury referral form is to ensure that workplace injuries are properly reported and that employees receive the necessary medical care and compensation.

What information must be reported on work injury referral form?

The work injury referral form typically requires information about the injured employee, the circumstances of the injury, and any medical treatment received.

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