EMPLOYEE’S CLAIM FOR COMPENSATION/REPORT OF INITIAL TREATMENT FORM C-4 PLEASE TYPE OR PRINT EMPLOYEE’S CLAIM – PROVIDE ALL INFORMATION REQUESTED First Name M.I. Last Name Birthdate Home Address Age City State City Height Zip Physical Address State INSURER Claim Number (Insurer’s Use Only) Sex M F Weight Social Security Number Telephone Zip Primary Language Spoken Employee’s Occupation (Job Title) When Injury or Occupational Disease Occurred THIRD-PARTY ADMINISTRATOR Employer’s Name/Company Name Telephone Office Mail Address (Number and Street) Date of Injury (if applicable) Hours Injury (if applicable) am Address or Location of Accident (if applicable) Date Employer Notified Last Day of Work After Injury or Occupational Disease Supervisor to Whom Injury Reported pm What were you doing at the time of the accident? (if applicable) How did this injury or occupational disease occur? (Be specific and answer in detail. Use additional sheet if necessary) Witnesses to the Accident (if applicable) If you believe that you have an occupational disease, when did you first have knowledge of the disability and its relationship to your employment? Nature of Injury or Occupational Disease Part(s) of Body Injured or Affected I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE PROVIDED THIS INFORMATION IN ORDER TO OBTAIN THE BENEFITS OF NEVADA’S INDUSTRIAL INSURANCE AND OCCUPATIONAL DISEASES ACTS (NRS 616A TO 616D, INCLUSIVE OR CHAPTER 617 OF NRS). I HEREBY AUTHORIZE ANY PHYSICIAN, CHIROPRACTOR, SURGEON, PRACTITIONER, OR OTHER PERSON, ANY HOSPITAL, INCLUDING VETERANS ADMINISTRATION OR GOVERNMENTAL HOSPITAL, ANY MEDICAL SERVICE ORGANIZATION, ANY INSURANCE COMPANY, OR OTHER INSTITUTION OR ORGANIZATION TO RELEASE TO EACH OTHER, ANY MEDICAL OR OTHER INFORMATION, INCLUDING BENEFITS PAID OR PAYABLE, PERTINENT TO THIS INJURY OR DISEASE, EXCEPT INFORMATION RELATIVE TO DIAGNOSIS, TREATMENT AND/OR COUNSELING FOR AIDS, PSYCHOLOGICAL CONDITIONS, ALCOHOL OR CONTROLLED SUBSTANCES, FOR WHICH I MUST GIVE SPECIFIC AUTHORIZATION. A PHOTOSTAT OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL. Date Place Employee’s Signature THIS REPORT MUST BE COMPLETED AND MAILED WITHIN 3 WORKING DAYS OF TREATMENT Place Name of Facility Date Diagnosis and Description of Injury or Occupational Disease Hour Is there evidence that the injured employee was under the influence of alcohol and/or another controlled substance at the time of the accident? No Yes (if yes, please explain) Have you advised the patient to remain off work five days or more? Treatment: Yes Indicate dates: from ____________ to __________________ No X-Ray Findings: If no, is the injured employee capable of: full duty modified duty If modified duty, specify any limitations/restrictions: _______________________ From information given by the employee, together with medical evidence, can you directly Yes No connect this injury or occupational disease as job incurred? Is additional medical care by a physician indicated? Yes _________________________________________________________________ _________________________________________________________________ No Do you know of any previous injury or disease contributing to this condition or occupational disease? Date Print Doctor’s Name No (Explain if yes) I certify that the employer’s copy of this form was mailed to the employer on: INSURER’S USE ONLY Address City Yes State Zip Provider’s Tax I.D. Number Doctor’s Signature ORIGINAL – TREATING PHYSICIAN OR CHIROPRACTOR Telephone Degree PAGE 2 – INSURER/TPA PAGE 3 – EMPLOYER PAGE 4 – EMPLOYEE Form C-4 (rev.01/03) American LegalNet, Inc. www.FormsWorkflow.com