en-USJurisdiction Claim Number (JCN)en-USClaim Administrator Number Date of Birth þ Date of Injury/Occupational Disease City þ State Zip Code en-USAddress of Company/Employer en-USPatient222s Nameen-USAddress en-USName of Company/Employeren-USHas patient reached maximum medical improvement? Yes No en-US en-USWas there any fracture or amputation? Yes Noen-US en-US en-USen-USen-USDATEen-USen-USAddress City þ þ State Zip Code en-USAttending Physicianen-USen-USDate of first visiten-USen-USen-USen-USDates of treatmenten-US en-USen-USNature of treatmenten-US en-USFindings and Diagnosis en-USInjured Worker Information en-USAttending Physician222s Report en-US en-USen-USen-US/ /en-USen-USen-US en-US/ /en-US/ /en-USRev.en-US 12/18en-USToll-Free:en-USen-US| Online: en-USen-US en-US| en-USMail:en-US en-USen-USDateen-US/ / American LegalNet, Inc. www.FormsWorkFlow.com en-USAttending Physician222s Report Process & Instructions en-USAttending Physician222s Reporten-USen-USen-USen-USInstructionsen-USen-US p en-US en-US en-USoven-USen-USen-USen-USen-US en-USToll-Free:en-USen-US | Online: en-USen-US en-US | en-USMail:en-US en-US en-USAmputation for Hand/Footen-USen-USAmputation Chart located at en-US p en-US en-US en-USov/content/am p en-USen-US American LegalNet, Inc. www.FormsWorkFlow.com