Eastern Connecticut State University Apparel 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's last name, first name, and middle initial in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the birth date and IMRF Member ID or the last four digits of the SSN. This section is mandatory for processing.
4. In the red box section, provide a detailed diagnosis along with any concurrent conditions using ICD 9 codes. This information must be complete for the form to be valid.
5. Document all treatments or services provided, including dates and descriptions of medical services rendered. Attach office notes to avoid delays.
6. Indicate whether the patient was continuously disabled and provide a 'From' and 'Through' date. This is essential for validating the claim.
7. Answer questions regarding employment-related injuries, recommendations to stop working, and any previous similar conditions. Be thorough in your responses.
8. Finally, ensure that a licensed physician signs the form, providing their name, degree/specialty, contact information, and date. The form will not be processed without this signature.

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