Please view and fill out the forms below prior to your visit. You have the option of printing then completing the forms by hand or filling them out digitally and printing the completed forms. We appreciate your time to prepare for your appointment.
Information for Uninsured Patients
There are special reporting requirements that must be met to guarantee that the benefits due under workers’ compensation programs are received.
Patients must provide the following:
• Social Security Number.
• Compensation insurance carrier, claim number, contact name, contact phone number(s) and fax number.
• Employer name, HR contact person and phone number.
• Date of injury information and a copy of the first report of injury document.
The document may be faxed by your employer to us at 540-722-4514.
We will provide copies of reports to one party from whom other related parties may obtain their copies.
Unless instructed otherwise, we will assume this is the insurance carrier.