INJURED WORKER CONTACT (PRIOR INJURY & PRE-EXISTING CONDITION FOLLOW-UP) CLAIMS DIVISION SFN 51153 (11/2010) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com PLEASE PRINT OR TYPE USING BLACK OR BLUE INK Injured Worker 1. 2. Claim Number Body Part (s) Before your current injury, have you ever had any injuries or health problems, work related or not, to this area of your Yes No If no, skip to questions 13-18. If yes, please continue. body? How did your past injury or condition occur? 3. How long ago was the past injury or condition? 4. What was the diagnosis for your past injury or condition? 5. Please list any medical doctor, chiropractor, physical therapist, occupational therapist, or other health care professional that you treated with for your past injury or condition. (Continue on back if needed). Complete Name Address City, State, Zip Phone Time Frame 6. When was the last time you were treated for your past injury or condition? 7. What type of treatment did you receive? (Medical doctor, chiropractor, physical therapist, etc.) 8. When was the last time you took medication for your past injury or condition? 9. What is the name of the medication(s) you took for your past injury or condition? 10. Does the past injury or condition continue to cause you pain and discomfort? If yes, please explain. 11. Explain the limits the past injury or condition has had on your daily activities? 12. Do you have any of the following as a result of your past injury or condition? Loss of Motion Limp Prosthetic Deformity Scar Orthotic Yes No C96a American LegalNet, Inc. www.FormsWorkFlow.com INJURED WORKER CONTACT PAGE 2 OF 3 Claim Number 13. Injured Worker List all employers you have worked for in the last 10 years and what you did for each employer. Employer Name Address Telephone Dates Employed To From Duties: From To From To Duties: Duties: 14. Have you ever filed any other workers compensation or personal injury claims, in any state, for injuries or health problems? Yes No If yes, in what state(s)? Name of insurance company: When? Type of injury: 15. Have you ever received a permanent disability, impairment, or percentage rating in the past for any injury or health problems? Yes No If yes, in what state(s)? When? Name of insurance company: Type of injury: 16. Were you ever unable to work in the past due to injury or health problems? If yes, for how long? 17. In the past, has any doctor or medical provider told you to avoid certain physical activities because of an injury or health Yes No If yes, complete the following: problems? Restriction Doctor Who Initiated Restriction Dates From To Yes No From From 18. To To Please list the names and addresses of all medical providers that you see for your routine medical care. Complete Name Address City, State, Zip Phone Time Frame Fraud Warning for Filing False Claims Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers’ compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with the Fund, including injured workers, employers, medical providers, and attorneys. To report an instance of fraud, contact the ND Fraud and Safety Hotline at 1-800-777-5033. C96a American LegalNet, Inc. www.FormsWorkFlow.com INJURED WORKER CONTACT Claim Number PAGE 3 OF 3 Injured Worker AUTHORIZATION FOR RELEASE OF INFORMATION I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medical provider or facility, any insurance company, including workers’ compensation relating to work injuries, any law enforcement or military agency, any government benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including records pertaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS related illness. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of resolving claims against third parties. I authorize the release of any medical information related to my claim to my employer. My signature below authorizes all providers listed on this form to release both prior and current medical information to WSI. This release will remain in effect until revoked by me in writing. Injured Worker’s Signature Date C96a American LegalNet, Inc. www.FormsWorkFlow.com