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Disability Form
 

Verification of Worker's Compensation

Worker’s Compensation nurses may use this form to communicate with the OA Worker’s Compensation Liaison.

*Date: (mm-dd-yyyy)

Employee Information:

  
*Employee:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
*Phone Number: (555-123-4567)
*Date of Birth: (mm-dd-yyyy)

Employer Information:

  
*Employer:
*Phone Number: (555-123-4567)
Fax Number: (555-123-4567)
*Date of Injury: (mm-dd-yyyy)

Address to Send Bill/Report:

  
*Recipient Name:
*Street Address 1:
Street Addresss 2:
*City:
*State:
*Zip Code:
Insurance Carrier:
*Street Address 1:
Street Addresss 2:
*City:
*State:
*Zip Code:
Phone Number: (555-123-4567)
Fax Number: (555-123-4567)
Claim Number:
*Person Handling Claim:
Case Worker:
*Phone Number: (555-123-4567)
Fax Number: (555-123-4567)
*Submitter's Email: