Asignment Type

Submission Date:

Your Case/Claim #:

Authorization Length:

1 Week2 Weeks3 Weeks1 Month2 Months3 Months4 Months5 Months6 Months1 YearIndefiniteOther <<Select one, if Other explain here --->

Requestor Title:

Case ManagerAdjusterProviderClaimantLawyerOther <<Select one, if Other explain here --->

CLIENT INFORMATION

Billing Goes To (Name of Ins. Co.):

Billing Address:

Billing City:

Billing State:

Billing ZIP:

Client Phone:

   Extension:

Client FAX:

Client E-mail Address:

ADJUSTER INFORMATION

Contact Person Y/N: 

Adjuster Name:

Adjuster Phone:

   Extension:

Adjuster FAX:

Adjuster E-Mail:l

CASE MANAGER INFORMATION

Contact Person Y/N: 

Case Manager Name:

Case Manager’s Company Name:

Case Manager Phone:

   Extension:

Case Manager FAX:

Case Manager E-Mail:

CLAIMANT INFORMATION

Your Claim/Case Number:

Claimant Name:

Claimant DOB:

Claimant SSN:

Claimant Street Address:

Claimant City:

Claimant State:

Claimant ZIP:

Claimant Delivery Address:

Claimant Delivery City:

Claimant Delivery State:

Claimant Delivery ZIP:

Claimant Phone:

Claimant Type of Injury:

Claimant Date of Injury:

Claimant Injury Diagnosis

Claimant Measurements:

Height ---  Feet:   Inches:

 Weight:

Claimant Has Wheelchair???

  Y/N: 

Claimant Emergency Contact:

Claimant Emergency Contact Relation:

Claimant Emergency Contact Phone:

Claimant Lives in:

Apartment 

Floor # 

House: 

# of Floors 

CLAIMANT’S EMPLOYER

Employer Name:

Employer Street Address:

Employer City:

Employer State:

Employer ZIP:

Employer Contact Name:

Employer Contact Phone Number:

  Extension:

Employer Contact FAX Number:

CLAIMANT’S DOCTOR

Doctor’s Name

Doctor’s UPIN #

Doctor’s Office Name

Doctor’s Office Street Address

Doctor’s Office City

Doctor’s Office State

Doctors Office ZIP

Doctor’s Office Contact

Doctor’s Office Phone

Doctor’s Office Fax

MEDICAL SUPPLIES - DURABLE MEDICAL EQUIPMENT - OTHER SUPPLIES

QTY

ITEM DESCRIPTION

ITEM #

HCPC