Get Ca Ortho La Verification Of Work-related Injury 2020-2025

The CA Ortho LA Verification Of Work-Related Injury form is essential for documenting work-related injuries for patients. This guide provides a clear and supportive approach to help users fill out the form online with ease.

Follow the steps to fill out the CA Ortho LA Verification Of Work-Related Injury form online.

1. Press the ‘Get Form’ button to access the Verification Of Work-Related Injury form. This will open the document in an online editor for your convenience.
2. Begin by entering the patient’s name in the designated field. This must be the full legal name of the individual who sustained the injury.
3. In the next section, input the patient's date of birth (DOB) in the appropriate format. This helps verify the identity of the patient.
4. Provide the patient's address, ensuring all details such as street address and city are included.
5. Enter the patient’s social security number (SSN) in the specified field. Be mindful to keep this information confidential.
6. Fill in the patient’s phone number for any necessary follow-up communication regarding the injury.
7. Document the date and time of the injury or illness, choosing either am or pm as appropriate.
8. Indicate any alternative phone number for the patient, if available, to ensure they can be reached.
9. Specify the place where the accident occurred, providing complete and accurate details.
10. Select the parish where the injury took place, if applicable.
11. Identify the area of the body that was injured and specify which side of the body is affected—left or right.
12. Input the name of the employer and provide their address in the fields provided.
13. Fill in the occupation of the patient to provide context about their role at the employer's establishment.
14. Include the case manager's name, along with their phone number and fax number for communication purposes.
15. Add the case manager’s email address, if available, to facilitate further correspondence.
16. Identify the company physician’s name and contact details for additional medical support.
17. Confirm that the employer acknowledges the work-related injury and understand their responsibilities regarding compensation.
18. Select the relevant authority under which the injury falls, marking the appropriate boxes as necessary.
19. Provide the medical claims address, ensuring all relevant details are included for where the claims should be sent.
20. Fill out the work-related claim number if applicable, ensuring it corresponds with the specific case.
21. Complete the section for faxing the completed form, mainly, the number 985.625.2201.
22. Enter the date when the accident was reported to ensure an accurate timeline.
23. Add the adjuster’s name, phone number, fax number, and email for clarity in claims handling.
24. The authorized employer representative should sign and print their name along with the date of signing.
25. Once all information is complete, save your changes. You can download, print, or share the form as needed.

Complete your CA Ortho LA Verification Of Work-Related Injury form online today to ensure timely processing of your claims.