Free - Nevada


File Size: 54.1 kB
Pages: 1
Date: January 10, 2003
File Format: PDF
State: Nevada
Category: Workers Compensation
Author: jdenison
Word Count: 532 Words, 3,666 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dirweb.state.nv.us/FORMS/c-4.pdf

Download ( 54.1 kB)


Preview
EMPLOYEE'S CLAIM FOR COMPENSATION/REPORT OF INITIAL TREATMENT FORM C-4 PLEASE TYPE OR PRINT EMPLOYEE'S CLAIM ­ PROVIDE ALL INFORMATION REQUESTED
First Name Home Address City Physical Address INSURER Employer's Name/Company Name Office Mail Address (Number and Street) Date of Injury (if applicable) Hours Injury (if applicable) pm Date Employer Notified Last Day of Work After Injury or Occupational Disease Supervisor to Whom Injury Reported State City M.I. Last Name Birthdate Age Zip State THIRD-PARTY ADMINISTRATOR Zip Height Sex M F Weight Telephone Primary Language Spoken Claim Number (Insurer's Use Only) Social Security Number

Employee's Occupation (Job Title) When Injury or Occupational Disease Occurred

Telephone

am Address or Location of Accident (if applicable)

What were you doing at the time of the accident? (if applicable) How did this injury or occupational disease occur? (Be specific and answer in detail. Use additional sheet if necessary)

If you believe that you have an occupational disease, when did you first have knowledge of the disability and its relationship to your employment?

Witnesses to the Accident (if applicable)

Nature of Injury or Occupational Disease

Part(s) of Body Injured or Affected

I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE PROVIDED THIS INFORMATION IN ORDER TO OBTAIN THE BENEFITS OF NEVADA'S INDUSTRIAL INSURANCE AND OCCUPATIONAL DISEASES ACTS (NRS 616A TO 616D, INCLUSIVE OR CHAPTER 617 OF NRS). I HEREBY AUTHORIZE ANY PHYSICIAN, CHIROPRACTOR, SURGEON, PRACTITIONER, OR OTHER PERSON, ANY HOSPITAL, INCLUDING VETERANS ADMINISTRATION OR GOVERNMENTAL HOSPITAL, ANY MEDICAL SERVICE ORGANIZATION, ANY INSURANCE COMPANY, OR OTHER INSTITUTION OR ORGANIZATION TO RELEASE TO EACH OTHER, ANY MEDICAL OR OTHER INFORMATION, INCLUDING BENEFITS PAID OR PAYABLE, PERTINENT TO THIS INJURY OR DISEASE, EXCEPT INFORMATION RELATIVE TO DIAGNOSIS, TREATMENT AND/OR COUNSELING FOR AIDS, PSYCHOLOGICAL CONDITIONS, ALCOHOL OR CONTROLLED SUBSTANCES, FOR WHICH I MUST GIVE SPECIFIC AUTHORIZATION. A PHOTOSTAT OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL.

Date Place Date Hour Treatment:

Place

Employee's Signature Name of Facility

THIS REPORT MUST BE COMPLETED AND MAILED WITHIN 3 WORKING DAYS OF TREATMENT

Diagnosis and Description of Injury or Occupational Disease

Is there evidence that the injured employee was under the influence of alcohol and/or another controlled substance at the time of the accident? No Yes (if yes, please explain)

Have you advised the patient to remain off work five days or more? Yes Indicate dates: from ____________ to __________________

X-Ray Findings:
From information given by the employee, together with medical evidence, can you directly Yes No connect this injury or occupational disease as job incurred?

No

If no, is the injured employee capable of:

full duty

modified duty

If modified duty, specify any limitations/restrictions: _______________________ _________________________________________________________________ _________________________________________________________________

Is additional medical care by a physician indicated?

Yes

No

Do you know of any previous injury or disease contributing to this condition or occupational disease? Date Address City State Zip Provider's Tax I.D. Number Telephone Degree Print Doctor's Name

Yes

No (Explain if yes)

I certify that the employer's copy of this form was mailed to the employer on: INSURER'S USE ONLY

Doctor's Signature

ORIGINAL ­ TREATING PHYSICIAN OR CHIROPRACTOR

PAGE 2 ­ INSURER/TPA

PAGE 3 ­ EMPLOYER

PAGE 4 ­ EMPLOYEE

Form C-4 (rev.01/03)