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Click ‘Get Form’ to open it in the editor.
Begin by entering the employee's name and the date of their last appointment in the designated fields.
Fill in the claim number and next office visit date to ensure accurate tracking of the case.
Indicate the job title and specify if the employee can return to work full duty without restrictions, or list any restrictions if applicable.
Complete the weight capacity section by indicating how much weight (in lbs) the patient can lift, carry, push, or pull for specified durations.
Mark whether the patient can perform various physical activities such as bending, climbing stairs, and using hands repetitively by placing an 'X' in the appropriate boxes.
Specify any additional limitations or recommendations that may affect the employee's return to work.
Finally, ensure that a physician's signature is included along with their printed name, specialty, and date before submitting.
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SEND BILLS TO: Sedgwick CMS. P.O. Box 14514. Lexington, KY 40512. Fax: 503-412-3990.
How do I send a fax to Sedgwick?
Send your updated medical documentation or certification form to Sedgwick via regular mail, fax, email or upload to the mySedgwick portal. The current status of your leave will determine appropriate next steps with this information.
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Sedgwick General Liability Intake Form
Email: SCMSNIC@SedgwickCMS.com Fax: 1-866-261-5795. Client Name: Contract Number: Reporter Information. First Name: Last Name: Title: Phone: Ext: Client
Send encrypted injury/incident reports as soon as possible to: injury.incident@sedgwickmco.com. Fax: Send injury forms to 888.711.9284. If an incident or injury
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