Follow the steps to accurately fill out the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the WSCC Claim Number at the top of the form. This number is essential for tracking the claim's progress.
3. Provide the name of the health care provider in the designated area. Please print clearly.
4. Enter the worker’s last name and first name. Make sure to spell these names correctly.
5. Fill out the worker's residential address, including the postal code for accurate identification.
6. Include a postal address if it differs from the residential address. Again, ensure that the postal code is provided.
7. Enter a telephone number, including the area code, for contact purposes.
8. Document the incident or injury date in the specified YY/MM/DD format.
9. Record the examination date, also using the YY/MM/DD format.
10. Fill in the date of birth of the worker using the specified format.
11. Specify the worker’s occupation.
12. State the employer’s name to provide context regarding the worker's role.
13. Answer the questions regarding who rendered the first treatment and the date treatment was first provided.
14. Detail what the worker says caused the injury to provide context for the assessment.
15. Describe any damage resulting from the incident, specifying if it pertains to dentures.
16. Use the provided symbols on the chart to indicate the condition of the worker’s teeth before and after the incident.
17. Describe in detail your treatment plan aimed at restoring the worker’s masticatory function to the level prior to the incident.
18. Indicate any other oral conditions that may exist, and provide your opinion on whether these are related to the incident.
19. Estimate the detailed treatment plan including itemized charges according to the Dental Association Fee Schedule.
20. Complete the form by signing as the health care provider, and ensure the date is recorded.
21. Review the entire form for completeness and accuracy before submission.
22. Finally, save changes, download, print, or share the completed form as needed.

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