Get Drs 10137

Filling out the Drs 10137 form is essential for individuals seeking reimbursement for income loss due to qualifying crime-related injuries. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the Drs 10137 form online.

1. Click the ‘Get Form’ button to access the Drs 10137 form and open it in a suitable online editor.
2. Begin by entering the victim's name clearly in the designated field.
3. Specify the date of injury by selecting or typing the appropriate date.
4. Indicate whether the injury was crime-related by selecting 'Yes' or 'No'.
5. Indicate whether the injury was work-related by selecting 'Yes' or 'No'.
6. Answer whether the victim was able to perform modified work-related duties during the disability period by selecting 'Yes' or 'No'.
7. Provide the diagnosis with the corresponding code(s) in the given section.
8. Clearly outline the prognosis for recovery in the designated area.
9. Fill in the dates of the disability period, specifying the start and end dates.
10. The physician or mental health provider must complete the certification section, including their name, state license number, address, and contact number.
11. Have the physician or mental health provider sign and date the form to affirm the accuracy of the information provided.
12. Once completed, review the form for any errors, then save changes, download, print, or share the completed document as necessary.

Complete your Drs 10137 form online today to ensure a smooth application process.