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Get Teamcare Claim Form 2 HW8AB 2014

8-9757 M E M B E R Participant ID: Employer: Full Name: Address: By signing below, I am certifying that I have not returned to work or retired: Signature of Participant Participant’s Phone Number Date Patient’s Name: Have any complications or other conditions arisen since the last medical update? Yes No If yes, please explain: P H Y S I C I A N Please list all dates of treatment related to this disability: Office Visits: Surgery/Hospital Date(s): ACTUAL OR ESTIMATED RETURN TO.

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