Immediately after receiving notice of an injury and medical treatment is anticipated, the agency should provide this informational form to the injured worker to give to the treating doctor. This form is designed to give information to the provider, such as agency contact information and billing information. It also provides the provider with a statement on the agency’s return-to-work policy, so the provider can determine if the patient is able to perform modified job duties.
The claims coordinator.
- Employee’s name and Social Security number.
- Name of agency.
- Name, title, and telephone number of claim coordinator.
Provide completed form to injured employee to give to treating doctor.
Mail to treating doctor if employee is not able to give to doctor.