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Initial Treatment Plan (Chiropractic Care-Massage Therapy-Other) Form. This is a Idaho form and can be use in Crime Victim Workers Compensation.
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Tags: Initial Treatment Plan (Chiropractic Care-Massage Therapy-Other), Idaho Workers Compensation, Crime Victim
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
IDAHO CRIME VICTIMS COMPENSATION PROGRAM
:
Initial Treatment Plan Calendar No.
! CHIROPRACTIC CARE
CV#:
Parent/Guardian:
Treatment Provider Name:
Credentials:
:
!
! MASSAGE THERAPY JUDICIAL SUBPOENA
Plaintiff(s)
-against-
:
Patient’s Name:
Tax I.D. #: :
:
Defendant(s)
:
Are you a provider under the following programs?
......................................................
! Medicaid
! Medicare
! TriCare
! Blue Cross
! Indian Health Services
! Blue Shield
Other
THE PEOPLE OF THE STATE OF NEW YORK
Indicate what sources of payment are available to this patient:
Date treatment began:
Number of sessions to date:
TO
1. Please describe the presenting symptoms or conditions for which the patient is seeking treatment.
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
2. Does Honorable have a history of any conditionsthe required similar treatment in the past?
,
the the patient
at that
Court
located at
! Yes ! No If so, please indicate the type of treatment, approximate dates and reasons for treatment.
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your a brief comply.
3. Please providefailure to description of the crime as related to you, including a description of the injury
sustained and the source of the information (i.e. patient, parent or other).
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
4. Please describe any pre-existing conditions that may affect treatment and to and type extent these
(Attorney must sign above what name below)
conditions may have been exacerbated by the crime.
Attorney(s) for
5. Indicate percentage of treatment you are providing that resulted from non-crime related injuries.
%
Office and P.O. Address
6. Describe the symptoms or conditions you are treating that are a direct result of the crime.
C:\formdocuments\Initial Treatment Plan – Chiro PT Massage (8/01)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
7. Indicate percentage of treatment you are providing for conditions that are a direct result of the crime.
:
Calendar No.
%
(Percentages from #5 and #7 should equal 100%)
8. Estimated duration of treatment:
Plaintiff(s)
from
-against-
:
JUDICIAL SUBPOENA
to
:
9. Estimated cumulative cost of treatment:
$
:
10. List below the treatment goals for this patient, give specific physical measures and projected dates to
:
achieve each goal.
Defendant(s)
:
................
.......... ....
Symptom/Condition . . . . . . . . Treatment .Goal . . . . . . . . . . . . . . . Method
Target Date
THE PEOPLE OF THE STATE OF NEW YORK
TO
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
, one of the Justices of the
County,
day of
, 20
14. I Court inthat the information provided in this treatment plan is true and accurate. I acknowledge
certify
that if the alleged offender is convicted, the Program will request the criminal court to order the alleged
offender to pay restitution to reimburse the Program for expenses paid on behalf of the patient. I further
understand that this document may be submitted as evidence(Attorney must sign above and type name below)
and that I may be called to testify
regarding the treatment outlined in this plan.
Signature of Treatment Provider
Attorney(s) for
Date
Title
Office and P.O. Address
C:\formdocuments\Initial Treatment Plan – Chiro PT Massage (8/01)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
