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New Workers' Compensation Intake Form ONLY - OrthoDoc aaos.org - orthodoc aaos

New Workers' Compensation Intake Form ONLY - OrthoDoc aaos.org - orthodoc aaos 2025

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The document is a Workers' Compensation Intake Form from Edward Diao, MD, located in San Francisco. It collects patient demographics, injury details, medical history, and financial policies related to medical services. The form includes sections for personal information, employment details, insurance information, and a health review. Additionally, it outlines the responsibilities of patients regarding controlled substances prescribed by the physician.

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How to use or fill out New Workers' Compensation Intake Form ONLY - OrthoDoc aaos.org - orthodoc aaos

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Click ‘Get Form’ to open it in the editor.
Begin by indicating whether the injury is work-related by selecting 'Yes' or 'No' at the top of the form.
Fill in your demographics, including your name, email, address, date of birth, and social security number. Ensure all information is accurate for effective communication.
Provide your employment details such as employer's name and contact information. This section is crucial for processing your claim.
Complete the WC Insurance section with the name of your workers' compensation carrier and claim number. Include any relevant dates and addresses.
In the Patient’s Current Injury section, describe how the injury occurred and its impact on your daily activities. Be thorough to assist in proper assessment.
List any past medical history, medications, and allergies in their respective sections to provide a comprehensive health overview.
Review all entries for accuracy before submitting. Use our platform's features to save or print a copy for your records.

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