Free Workers' Compensation Attending Physician Benefits Form Return completed form to... - West Virginia

Workers' Compensation Attending Physician Benefits Form
Return completed form to the Third-Party Administrator American M ining Claims Service PO Box 6 6 0988 Birmingham, AL 3526 6 -0988 Fax: 86 6 -759-9843
Claimant Name: Date of Injury: Employer: Social Security Number: Claim Number: Physician Name:

Estimated

Transitional

Full Duty Return-To-Work Date: Yes No Yes No To Next Appointment Date:

Physician

Maximum Medical Improvement:

Ready for Permanent Partial Disability Rating: Estimated Period of Disability From Current Appointment Date:

Physicians completing this form are required to submit updated detailed medical reports to include current treatment plans related to this claim in a timely manner after each office visit. The completion of this form without the detailed medical information noted above does not guarantee that temporary total disability benefits will be paid. Physician's signature: __________________________________ Date: _____________________

Have you performed any kind of work or have you received income for any work during the Yes No time you have been certified temporarily and totally disabled?

Claimant

I hereby certify that the statement and answer set forth above are true and correct to the best of my knowledge and belief. I am aware that the law provides for severe penalties if I knowingly and with fraudulent intent withhold a material fact or make a false statement in order to obtain or increase a benefit to which I am not entitled. Claimant's signature: ___________________________________ Date: _____________________

Failure to complete this form in its entirety will affect the payment of temporary total disability benefits in this claim.