Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by completing the patient information section. Provide the patient’s full name, date of birth, social security number, address, home phone, cell phone, and email.
3. Next, fill out the employer information. Include the employer's name, phone number, address, city, state, and ZIP code.
4. Move on to the billing information section. Enter the scheduling party's name, phone number, and email address. Ensure that the billing party details are accurate.
5. Complete the adjuster information. Fill in the adjuster's name, phone number, fax number, and email address.
6. Provide the carrier address, city, state, ZIP code, jurisdiction, claim number, date of injury, and specify the body part(s) to be evaluated.
7. Enter the requested date of services and the specified provider you are requesting for the evaluation.
8. By signing the form, you authorize OrthoCarolina to provide the requested services. Review all your information for accuracy before signing.
9. After completing the form, save your changes. You can then choose to download, print, or share the completed form as necessary.

Take the next step and complete your OrthoCarolina Workers’ Compensation Special Exam Information Form online today.