Narendra Kansal, MD - Publicforms

Available Forms

APPOINTMENT REQUEST BACK OR LEG DISABILITY FORM HIPPA NOTICE/ CONSENT FORM MEDICATION REFILL REQUEST NECK DISABILITY FORM NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM NO FAULT CLAIMANT HISTORY FORM NO FAULT INFORMATION SHEET PATIENT INFORMATION PART 2 PATIENT INFORMATION SHEET 1 RECORDS RELEASE FORM REVIEW OF SYSTEMS Welcome to our Neurosurgery practice. WORKERS COMPENSATION INFORMATION SHEET

WORKERS COMPENSATION INFORMATION SHEET

PLEASE FILL IN THE FOLLOWING INFORMATION COMPLETELY. INCOMPLETE FORMS WILL RESULT IN YOUR APPOINTMENT BEING RESCHEDULED.

NAME *

DATE *

EMPLOYMENT INFORMATION

EMPLOYER WHEN INJURY OCCURRED

PHONE NUMBER *

ADDRESS WHERE INJURY OCCURED *

EMPLOYERS INSURANCE INFORMATION

EMPLOYERS INSURANCE CARRIERS NAME *

PHONE NUMBER *

ADDRESS *

CLAIM ADJUSTER'S NAME *

EXTENSION NUMBER

INJURY INFORMATION

DATE OF INJURY *

DATE OF INJURY:

IF MORE THAN ONE INJURY. LEAVE BLANK IF NOT APPLICABLE.

DATE REPORTED TO EMPLOYER *

TYPE OF INJURY *

WHAT WAS YOUR JOB TITLE AT TIME OF INJURY? *

WHAT WERE YOUR USUAL WORK ACTIVITIES? *

PLEASE DESCRIBE HOW THE INJURY OCCURRED? *

HAVE YOU LOST ANY TIME FROM WORK DUE TO THE INJURY? *

YES

IF YES, WHAT DATES? *

IF NO, PUT N/A

ARE YOU CURRENTLY WORKING? *

YES

HAVE YOU EVER HAD THE SAME OR SIMILAR INJURY? *

YES

IF YES, DATE(S) OF PREVIOUS INJURY? *

IF NO, PUT N/A

HAVE YOU EVER BEEN TREATED BY ANOTHER DOCTOR FOR THIS INJURY? *

YES

IF YES, WHO WAS THE DOCTOR?

IS AN ATTORNEY OR A LICENSED REPRESENTATIVE REPRESENTING YOU? *

YES

IF YES, NAME,ADDRESS, PHONE#, FAX # OF REPRESENTATIVE *

IF NO, PUT N/A

*NOTICE THAT YOU MAY BE RESPONSIBLE FOR MEDICAL COSTS IN THE EVENT OF FAILURE TO PROSECUTE, OR IF COMPENSATION CLAIM IS DISALLOWED, OR IF AGREEMENT PURSUANT TO WCL §32 IS APPROVED*

WCB CASE NUMBER *

CASE CARRIER NUMBER *

DATE OF INJURY *

NATURE OF INJURY OR ILLNESS *

SOCIAL SECURITY NUMBER *

CLAIMANT

NAME *

ADDRESS *

EMPLOYER

NAME *

ADDRESS *

INSURANCE CARRIER

NAME *

ADDRESS *

You may become responsible for the medical costs of treatment for your illness or condition with the provider listed below if (1) you fail to prosecute the claim for workers' compensation or (2) it is determined by the Workers' Compensation Board that the illness or condition which required treatment was not a result of a compensable workplace accident or occupational disease or (3) if an agreement is executed by you and approved pursuant to Workers' Compensation Law §32 in which you waive your right to medical benefits from the workers' compensation carrier/self-insured employer for treatment/services performed after the date the agreement is approved. If any of the above events occurs, the provider may bill you directly instead of the employer or insurance carrier, and you will be responsible for the provider's fees for services rendered.

I hereby acknowledge that I have read the above and understand the circumstances under which I may become responsible for payment.

SIGNATURE *

DATE *

TO THE CLAIMANT

Workers' Compensation Board Regulation 325-1.23 permits your doctor or therapist to request that you sign this A-9 notice. By signing this notice, you acknowledge your obligation to pay the provider's fees for the services you receive if it turns out that such fees are not legally required to be paid by your employer or its workers' compensation insurance carrier and if such fees are not covered by other insurance. The employer or carrier may not be required to pay the doctor's fees if, for example, you fail to file a claim for workers' compensation, or fail to notify your employer of your injury or illness, or fail to attend a Board hearing if your employer challenges your right to benefits. Even if you make all required efforts to prosecute your claim, the Workers' Compensation Board may still find that you are not entitled to benefits. In such cases, this notice advises your health provider that you acknowledge your personal liability for payment of his/her bills.Workers' Compensation Law Section 32. The A-9 notice also covers instances in which a claimant with an existing valid workers' compensation case comes to an agreement with his/her employer or its insurance carrier settling his/her case in accordance with Section 32 of the Workers' Compensation Law. A Section 32 agreement may include a provision which relieves the employer or carrier of the liability to pay future medical bills associated with the case. Your health care provider may ask you to sign this A-9 notice to insure that you acknowledge your personal liability for payment of his/her bills if you have waived your right to future medical benefits under a Section 32 agreement.If you have any questions, contact your attorney or licensed hearing representative, if you have one. You may also contact your local district office of the Workers�?? Compensation Board.

TO THE HEALTHCARE PROVIDER

This notice is meant to advise the workers' compensation claimant that he/she may be responsible for payment. Failure of the claimant to sign this form does not relieve the provider of the obligation to treat the claimant, nor does it negate the claimant's responsibility for payment.Keep the original of this form for your records and give a copy to the claimant. Do not file with the Workers' Compensation Board. You will receive Notices of Decisions in which the compensability of a claim, authorization of treatment, or payment of medical bills is included. You will also be notified if the claimant submits a Section 32 Agreement with the Board for approval. Do not bill the claimant unless and until you receive a Board decision finding that 1) claimant failed to prosecute the claim, or 2) the claim is denied, or 3) the treatment is not causally related to the work injury, or 4) a Section 32 agreement relieving the carrier of liability for medical treatment is approved.

CLAIMANY HISTORY FORM

HOW DID/WILL YOU GET TO OUR OFFICE? *

BUS

TRAIN

TAXI

WALK

CAR

OTHER

IF CAR, DID/WILL YOU DRIVE YOURSELF? *

HISTORY

WHAT AREA(S) OF YOUR BODY WAS (WERE) INJURED: *

WHAT MEDICAL CARE OCCURRED THE DAY OF THE ACCIDENT/INJURY: *

DID YOU GO TO THE HOSPITAL? *

YES

IF YES, WHAT HOSPITAL? *

IF NO, PUT N/A

WERE YOU ADMITTED? IF YES, HOW LONG? *

IF YOU DID NOT GO TO THE HOSPITAL, PUT N/A

TREATMENT

PLEASE LIST THE HEALTH CARE PROVIDERS YOU HAVE SEEN FOR THIS INJURY. PLEASE INDICATE THEIR SPECIALTY. *

IF NONE, PUT N/A

DESCRIBE ANY TREATMENT YOU HAVE UNDERGONE (INCLUDE PHYSICAL THERAPY, ACUPUNCTURE, SURGERY, CHIROPRACTIC ADJUSTMENTS, ECT) *

PLEASE IDENTIFY ANY MEDICATIONS YOU HAVE TAKEN FOR THIS INJURY *

HAVE YOU BEEN GIVEN ANY MEDICAL EQUIPMENT FOR HOME USE? IF YES, WHAT EQUIPMENT? *

if none, put n/a

WORK HISTORY

ANY RESTRICTED DUTY? *

YES

DESCRIBE ANY TYPE OF WORK YOU ARE CURRENTLY DOING (INCLUDING RESTRICTIONS) *

IF YOU ARE NOT WORKING, WHAT SPECIFICALLY DO YOU FEEL PROHIBITS YOU FROM RETURNING TO WORK? *

IF WORKING, PUT N/A

PRESENT COMPLAINTS

LIST ALL SYMPTOMS & COMPLAINTS RELATED TO THIS INJURY? *

PAST MEDICAL HISTORY

HAVE YOU HAD ANY PRIOR MOTOR VEHICLE ACCIDENTS? IF YES, PROVIDE DATES & INJURIES. *

HAVE YOU HAD ANY PRIOR WORKERS COMPENSATION INJURIES? IF YES, PROVIDE DATES AND INJURIES *

HAVE YOU UNDERGONE ANY PREVIOUS SURGERY? IF YES, PROVIDE DATES AND TYPE OF SURGERY: *

DAILY LIVING

WHAT ACTIVITIES ARE YOU ABLE TO PERFORM AND WHAT ACTIVITIES ARE YOU UNABLE TO PERFORM? (I.E HOW LONG CAN YOU STAND, SIT, LIE DOWN?) *

WHAT DAILY ACTIVITIES ARE YOU CAPABLE/INCAPABLE OF PERFORMING? (I.E COOKING, CLEANING, TENDING TO PERSONAL HYGIENE, TAKING CARE OF CHILDREN, SHOPPING, ERRANDS) *

HOW DO YOU SPEND YOUR AVERAGE DAY? *

* Required field