CLIENT PERIODIC REVIEW

Download Blank PDF

Name*
Please write your current address here.*
Please write your email address and phone number(s) where we can reach you.*
Please tell us the name, address and telephone of the health care provider(s) you are treating with, what treatment you are receiving, and who is paying for it. If you are not treating, please say so.*
Are you taking any medications? If so, provide the name of the medication(s), the dosage, and the frequency that you use it, and who pays for it.*
Have you developed any new problems that you think are related to your work injuries? Please explain.*
Are you currently employed? If so, who is your employer?*
Are you receiving Social Security Disability Income (SSDI) or Social Security Supplemental Income (SSI)? If so, please state the date when you received your SSDI or SSI award. If you are not receiving SSDI or SSI, are you interested in pursuing that benefit?*
Are you currently Medicare eligible, even if you are not using Medicare at this time? If so, please state the date when you became Medicare eligible.*
Would you be interested in settling your claim and receiving a lump sum settlement?*
Email
This field is for validation purposes and should be left unchanged.