Get Ri Affidavit 28 33 Form

The Ri Affidavit 28 33 Form is an essential document for providing medical information in relation to workers' compensation cases in Rhode Island. This guide will assist you in filling out the form online with clear, step-by-step instructions tailored to your needs.

Follow the steps to complete the Ri Affidavit 28 33 Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the employee information section. Enter the last four digits of the employee's Social Security Number, their full name, date of birth, address, and phone number.
3. Next, complete the employer information section. Provide the employer's name, address, city, state, zip code, and phone number.
4. In the insurance carrier section, enter the name of the insurance carrier responsible for the employee's coverage.
5. For the adjusting company section, provide the name and contact details of the claims adjuster or company handling the case.
6. Fill out the employee's injury information, including the date of injury and the incapacity date.
7. In the treatment section, describe the current and anticipated treatment plans, types, frequency, and duration of treatments. If there are no treatments, state this clearly.
8. Indicate the anticipated date of discharge. If the employee has been discharged, clearly state that.
9. Answer the questions regarding the employee's ability to return to their previous job, and if they can work in a different capacity. Provide details on any work restrictions or capabilities.
10. Mark whether the employee has reached maximum medical improvement.
11. The physician should provide their signature, license number, name, title, and the name and address of their facility. Ensure all fields are filled out accurately.
12. Finally, place the date and include a signature for the notary public to verify the document. Ensure the form is completed and ready for submission.
13. Once all information is entered, you can save changes to the form, download it, print it, or share it as needed.

Start filling out the Ri Affidavit 28 33 Form online today to ensure your workers' compensation case is properly documented.