Workers' Compensation Patient Form - English

Required fields are marked with an asterisk *.

Name *

Address

Telephone *

E-mail

What hospital did you go for treatment?

Date of injury or accident

Employer Name

Address

Name

Contact Phone

Name

Address

If you know it, please provide a claim number

If you know it, please provide the name of your claims adjuster

Name of Health Insurance Company

Name of individual whose whole name is on the policy

Identification Number

Group Number

Have you hired an attorney to help you in this matter?

Yes

Attorney Name

Attorney Address

Attorney Phone

Rate Your Experience

Thank you

We have receive your response and are in the process of reviewing your submission.

Kind regards,

Parallon

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