WORKERS_COMPENSATION

Patient details

Patient / employee information

Last name

First name

Address

Apartment number

City

State

ZIP code

Email address

Home phone

Phone number

Date of birth

Age

Sex

MaleFemale

Social Security number (optional)

Occupation

Pharmacy

Pharmacy name and address

Pharmacy phone

Law firm

Law firm name

Phone number

Fax number

Email

Patient signature (type full name)

Date signed

Employer & injury

Employer

Employer name

Employer address

Employer phone

Type of business (retail, manufacturing, construction, etc.)

Workers’ compensation claim

Workers’ Compensation insurance carrier

Insurance carrier address

WCB case number (if known)

Claim administrator claim number (if known)

Injury / illness

On what date did your injury occur?

What time?

What address were you at when you were injured?

Nature of injury or illness

Did you notify your employer of this injury?

YesNo

Have you retained an attorney?

YesNo

If yes, please give the attorney’s name and address

Are you currently in litigation for this injury?

YesNoMaybe

Please explain how the injury or illness occurred

What injuries did you suffer?

Treatment & work

Work and first examination

When was the last day you worked?

When did you return to work?

When was your first examination?

Who examined you?

Check one, if known

D.C.M.D.D.O.D.D.S.

What was the doctor’s diagnosis?

Medical-cost notice

Notice that you may be responsible for medical costs in the event of failure to prosecute, or if compensation claim is disallowed, or if agreement pursuant to WCL §32 is approved

WCB case no. (if known)		Claim admin claim number (if known)
Date of injury		Nature of injury or illness
Claimant’s Social Security no.
Claimant name
Claimant address / apt. no.
Employer name / address
Insurance carrier name / address

These details come from the Patient and Injury sections.

You may become responsible for the medical costs of treatment for your illness or condition with the health care provider listed below if (1) you fail to prosecute the claim for workers’ compensation or (2) it is determined by the Workers’ Compensation Board that the illness or condition which required treatment was not a result of a compensable workplace accident or occupational disease or (3) if an agreement is executed by you and approved pursuant to Workers’ Compensation Law §32 in which you waive your right to medical benefits from the workers’ compensation insurer/self-insured employer for treatment/services performed after the date the agreement is approved. If any of the above events occurs, the provider may bill you directly instead of the employer or insurance carrier, and you will be responsible for the provider’s fees for services rendered.

I hereby acknowledge that I have read the above and understand the circumstances under which I may become responsible for payment.

I acknowledge that I have read and understand the medical-cost notice above.

Claimant’s signature (type full name)

Date signed

Provider’s name and address

To the claimant

Workers’ Compensation Board Regulation 325-1.23 permits your health care provider to request that you sign this A-9 notice. By signing this notice, you acknowledge your obligation to pay the provider’s fees for the services you receive if it turns out that such fees are not legally required to be paid by your employer or its workers’ compensation insurance carrier and if such fees are not covered by other insurance. The employer or insurer may not be required to pay the provider’s fees if, for example, you fail to file a claim for workers’ compensation, or fail to notify your employer of your injury or illness, or fail to attend a Board hearing if your employer challenges your right to benefits. Even if you make all required efforts to prosecute your claim, the Workers’ Compensation Board may still find that you are not entitled to benefits. In such cases, this notice advises your health provider that you acknowledge your personal liability for payment of their bills.

Workers’ Compensation Law Section 32

The A-9 notice also covers instances in which a claimant with an existing valid workers’ compensation case comes to an agreement with their employer or its insurance carrier settling their case in accordance with Section 32 of the Workers’ Compensation Law. A Section 32 agreement may include a provision which relieves the employer or insurer of the liability to pay future medical bills associated with the case. Your health care provider may ask you to sign this A-9 notice to insure that you acknowledge your personal liability for payment of their bills if you have waived your right to future medical benefits under a Section 32 agreement.

If you have any questions, contact your attorney or licensed hearing representative, if you have one. You may also contact your local district office of the Workers’ Compensation Board.

To the health care provider

This notice is meant to advise the workers’ compensation claimant that they may be responsible for payment. Failure of the claimant to sign this form does not relieve the provider of the obligation to treat the claimant, nor does it negate the claimant’s responsibility for payment.

Keep the original of this form for your records and give a copy to the claimant. Do not file with the Workers’ Compensation Board. You will receive Notices of Decisions in which the compensability of a claim, authorization of treatment, or payment of medical bills is included. You will also be notified if the claimant submits a Section 32 Agreement with the Board for approval. Do not bill the claimant unless and until you receive a Board decision finding that 1) claimant failed to prosecute the claim, or 2) the claim is denied, or 3) the treatment is not causally related to the work injury, or 4) a Section 32 agreement relieving the insurer of liability for medical treatment is approved.

A-9 (11-21) · Prescribed by Chair, Workers’ Compensation Board, State of New York (www.wcb.ny.gov).

Authorizations

Authorization and assignment

I, , hereby instruct and direct that my claim for Workers Compensation Health Care Benefits be assigned to:

FARSHAD D. HANNANIAN, M.D.
NEUROLOGIST
475 Northern Blvd Suite #18
Great Neck NY 11021

This is a direct Assignment of my claim and rights for Workers Comp Benefits. A photocopy of the Assignment shall be considered as effective and valid as the original. I shall also cooperate with the insurer with respect to attending physical examinations and completing all necessary paperwork.

Name

I agree to the authorization and assignment above.

Signature (type full name)

Date signed

Authorization for release of documented information from the insurance company to the provider

Patient’s name:
Date of accident:

I hereby am granting the medical provider, Dr. Farshad D Hannanian, treating me for my workers comp case, permission to obtain any and all information pertaining to my case. This includes PEER reviews, IME or any other documentation that the providing physician may need in order to obtain payment for my claim.

I authorize the release of information described above.

Patient signature (type full name)

Date signed

Patient consent form for neurological testing

I agree to give the consent that the neurodiagnostic study (NCV/EMG) of upper and Lower limbs be performed on me for the purpose of radicular and neuropathic pathology.

I consent to the neurological testing described above.

Patient signature (type full name)

Date signed

Privacy notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice is provided in two layers: This first layer briefly summarizes how we handle your health information; the second layer is a full copy in greater detail of our privacy policies and procedures and is prominently posted in our waiting room and copies of which are available and provided to you at our front desk.

How we many use and disclose your health information. We use health information about you for treatment, to get paid for treatment, for administrative purposes, and to evaluate the quality of care that you receive. For example, your health information may be shared with other providers to whom you are referred. Information may be shared by paper mail, electronic mail, fax, or other methods. We may use or disclose your health information without your authorization for several reasons. But beyond those situations, we will ask for your written authorization before using or disclosing your health information. If you sign an authorization to disclose information you can later revoke it to stop any future uses and disclosures.

Your rights. In most cases, you have the right to look at or get a copy of your health information that we use to make decisions about you. If you request copies, we may charge you a cost-based fee. You also have the right to request a list of certain types of disclosures of your information that we have made. If you believe your health insurance is incorrect or information is missing, you have the right to request that we correct the existing information or add missing information.

Our legal duty. We are required by law to protect the privacy of your health information, provide this notice about our privacy practices, follow the privacy practices that are described in this notice, and seek your acknowledgement of receipt of this notice. We may change our privacy policies anytime. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more information about our privacy policies, contact the person listed below.

Privacy complaints, if you are concerned that we have violated your policy rights, our privacy policies, or if you disagree with a decision we made about access to your health information, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.

If you have any questions or complaints, please contact: Farshad D. Hannanian, M.D.,

475 Northern Blvd. Suite 18 Great Neck, NY 11021. (516)-773-3048.

Acknowledgement of receipt of Notice of Privacy Practices: Please sign and print your name and provide the date below acknowledge that you have received both layers of this Notice of Privacy Practices. Then return this acknowledgement of receipt to the receptionist or to the address above.

Name

Patient’s name, if other than signature

I acknowledge receipt as described above.

Signature (type full name)

Date signed

Workers’ Compensation Intake

Patient details

Patient details

Patient / employee information

Pharmacy

Law firm

Employer & injury

Employer

Workers’ compensation claim

Injury / illness

Treatment & work

Work and first examination

Prior treatment and injuries

Work and symptom status

Medical-cost notice

Notice that you may be responsible for medical costs in the event of failure to prosecute, or if compensation claim is disallowed, or if agreement pursuant to WCL §32 is approved

To the claimant

Workers’ Compensation Law Section 32

To the health care provider

Authorizations

Authorization and assignment

Authorization for release of documented information from the insurance company to the provider

Patient consent form for neurological testing

Privacy notice