Get Ca Ortho La Verification Of Work-related Injury 2019

Filling out the CA Ortho LA Verification Of Work-Related Injury form online is a crucial step for individuals looking to verify injuries sustained at work. This guide will walk you through each section of the form to ensure accurate and complete submission.

Follow the steps to complete the verification form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name at the designated field. Ensure the name matches the identification documents.
3. Fill in the date of birth (DOB) in the provided area. Use the format MM/DD/YYYY for clarity.
4. Input the patient's primary address in the appropriate section, ensuring the details, including street name and number, are correct.
5. Enter the patient's social security number (SSN) in the specified field. This is often required for processing claims.
6. Provide the patient's primary phone number. If available, also fill in an alternate phone number.
7. Document the date and time of the injury or illness. Make sure to clarify whether it happened in the AM or PM.
8. Indicate the location of the accident in the designated section.
9. Complete the parish where the accident occurred.
10. Specify the area of the body that was injured and indicate the side, if applicable.
11. Fill in the name of the employer in the provided line.
12. Include the employer's address with accuracy. This may impact communication regarding the work-related injury.
13. Input the occupation of the patient within the workplace.
14. Record the name and contact information of the employer's case manager, including phone and fax numbers.
15. Indicate the case manager's email address, if available.
16. Provide the name of the company physician along with their contact details.
17. Choose the applicable workers' compensation laws that pertain to this case by checking the relevant boxes.
18. Specify the medical claims address to which services should be sent.
19. Enter the work-related claim number in the specified field.
20. Document the date when the accident was reported.
21. Finish the form by filling in the adjuster's name, phone number, fax, and email.
22. Obtain the authorized signature of the employer and ensure to print the name of the representative below the signature, along with the date of signing.
23. Save all changes, and you can choose to download, print, or share the completed form to ensure it is submitted appropriately.

Take action now and complete your CA Ortho LA Verification Of Work-Related Injury form online.