C96a PRIOR INJURY & PRE - EXISTING CONDITION QUESTIONNAIRE CLAIMS DIVISION SFN 51153 ( 1 1/2017 ) 1600 E C entury A ve , S te 1 PO Box 5585 Bismarck ND 58506 - 5585 Telephone 800 - 777 - 5033 Toll Free Fax 888 - 786 - 8695 TTY ( hearing impaired ) 800 - 366 - 6888 Fraud and Safety Hotline 800 - 243 - 3331 www. workforces afety.com SECTION 1 Claim number W orker (First name) (Last name) Body part(s) SECTION 2 Past medical treatment to claimed body area Before your current injury, have you ever had any problems, of any kind, in or around this area(s) of your body? Yes No If yes, please answer the rest of the questions in this section on all claimed body areas. If no, skip to section 3. When did you have these previous problem(s)? Have you ever had an evaluation or treatment of this body area(s)? Yes No What was the diagnosis(es) of your past problem(s)? Please list any and all medical providers (Medical Doctor, Chiropractor, Physical Therapist, Massage Therapist, etc.) who have treated a pr oblem(s) in this area(s) before this injury. Medical provider City State Telephone number Before this injury, when did you last receive any treatment (physical therapy, chiropractor, medication, injection, etc.) for this problem(s)? How is your current problem different from the past problem? SECTION 3 Past general medical treatment (Not related to claimed body area) Before this injury, have you missed more than a week from work due to any injury or pain problem? Yes No If yes, please list pain problem, cause, year, duration of unemployment, and state of residence at the time. Pain problem Cause Year Duration of unemployment State of residence Form is continued on next page. Please submit all pages to WSI. American LegalNet, Inc. www.FormsWorkFlow.com PRIOR INJURY & PRE-EXISITING CONDITION QUESTIONNAIRE SFN 51153 (12/2016) Claim number W orker (First name) (Last name) Before this injury, have you ever received chiropractic treatment for any reason? Yes No If yes, please list all past chiropractors Chiropractor City State Telephone number Before this injury, have you received treatment (medical, physical therapy, chiropractic, medication, etc.) for any pain problem lasting more than one month? Yes No If yes, please list diagnosis, year, and duration of treatment. Diagnosis Year Duration of treatment Please list names and location of all providers (medical, chiropractic, physical therapy, etc.) who have treated, provided ev aluation, of treatment of a pain problem involving a body area not part of this injury claim (for example: spine pain, headache, joint pai n, etc.) in the past 10 years. Medical provider City State Telephone number Please identify the providers that have provided any routine medical care in the past. Medical provider City State Telephone number Have you completed all above questions regarding all claimed body areas? Yes No If yes, please initial. If no, please explain why. 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) N ame of insurance company? When? Type of injury? Form is continued on next page. Please submit all pages to WSI. American LegalNet, Inc. www.FormsWorkFlow.com PRIOR INJURY & PRE- SFN 51153 (12/2016) Claim number W orker (First name) (Last name) C96a Have you ever received a pe rmanent disability, impairment, or percentage rating in the past for any injury or health problems? Yes No If yes, in what state(s) Name of insurance company? When? Type of injury? Were you ever unable to work in the past due to injury or health problems? Yes No If yes, for how long? In the past, has any doctor or medical provider told you to avoid certain physical activities because of an injury or health problems? Yes No If yes, complete the following Restriction Doctor who initiated restriction Dates From To From To From To SECTION 4 Release of information Release of information I understand and agree that North Dakota law determines all my rights an d obligations to and from WSI. I authorize any medical r military agency, any government benefit agency including the Social Security Administration, and any educ ational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including all prior records as well as those pe rtaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS - related illness. I authorize healthcare providers to respond to WSI regarding my injury, including request for conclusions and opinions not otherwise contained within existing medical records. In addition, I authorize any education agency or institution to release to WSI any and all ined by 20 U.S.S 21 Sec. 1232g. This authorization continues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulations. I authorize WSI to release any information or records about my claim to thi rd 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 . Fraud Warning 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 ensation 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 WSI, including injured workers, employers, medical provid ers, and attorneys Signature By signing this form, I acknowledge that I have read and understand the r elease of information and fraud w arning. I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substantial fines and i mprisonment. I authorize the release of information and agree that statements in this form are true and accurate. Date American LegalNet, Inc. www.FormsWorkFlow.com