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Job Injury / Accident Form

CONFIDENTIAL PATIENT INFORMATION

Dear Patient,

Please complete this questionnaire. Your answers will help us determine the most effective course of treatment. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. Thank You.

JOB INJURY INFORMATION

Complete this part only for Job Injury Information.

ACCIDENT INFORMATION

Complete this part only for Accident Information.

Headache Neck Pain Neck Stiff Sleeping Problems Back Pain Nervousness Tension Irritability Chest Pain Dizziness Head Seems Too Heavy Pins and Needles in Arms Pins and Needles in Legs Numbness in Fingers Numbness in Toes Shortness of Breath Fatigue Depression Light Bother Eyes Loss of Memory Ears Ring Face Flushed Buzzing in Ears Loss of Balance Fainting Loss of Smell Loss of Taste Diarrhea Feet Cold Hands Cold Stomach Upset Constipation Cold Sweats Fever

Assignment
If you wish to receive directly the First Party Automobile Benefits for services rendered to the above patient, please have the patient complete the following assignment. I hereby authorize payment directly to the above named Medical Provider of the automobile No-Fault Benefits otherwise payable to me, but not to exceed the balance due of the Medical Provider's permissible charges under Article 51 of the insurance law for services rendered.

Verification Code