Please return BLUE form to Criminal Injuries Compensation Fund, 11513 Allecingie Parkway, Richmond, Virginia, 23235 PHYSICIAN’S REPORT ON INJURY IN LIEU OF TESTIMONY Name of Patient_______________________________________________________ CICF Claim No.______________ Date of Injury_______/_______/_______ and the injury as described by the patient was________________________ __________________________________________________________________________________________________ Patient first seen in this office______/______/______ The extent and location of patient’s injuries were found to be __________________________________________________________________________________________________ Was there a disability for work? No £ Yes £ Date disability began_______/_______/_______ Date able to return to light work______/______/______ Date able to return to regular work______/______/______ Provide name of medication (brand/generic) and symptoms for which medication was prescribed. Medications prescribed for injury ____________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Has patient been discharged from your care? No £ Yes £ Have charges been filed for payment with anyone (other than CICF)? No £ Yes £ If yes, PENDING £ DENIED £ APPROVED £ If insurance, Company Name_________________________________________________________________ Address________________________________________________________________________ _______________________________________________________________________________ UNLESS OTHERWISE NOTED IN COVER LETTER, PLEASE INCLUDE THE PATIENT’S MEDICAL RECORDS AND ITEMIZED STATEMENT! † WITHOUT THIS INFORMATION, YOUR BILL CANNOT BE CONSIDERED FOR PAYMENT … Comments________________________________________________________________________________________ __________________________________________________________________________________________________ Signature of Physician____________________________________________ Telephone (_____)__________________ Type or Print Name______________________________________________________ Date_______/_______/_______ Rev. 08/00 American LegalNet, Inc. www.USCourtForms.com