First Report Of Injury {SFN 2828}

First Report of Injury continued on page 2. Submit both pages to WSI. F IRST REPORT OF INJURY CLAIMS DIVISION SFN 2828 (11 /201 7 ) 1600 E Century 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. w orkforce s afety.com SECTION 1 - Completion of this section is required Claim number (First name) (Last name) Social Security number* Date of birth Gender Female Male Marital status Single Married (Street address) City State ZIP code (Street address, PO Box number) City State ZIP code Date of injury Time of injury AM PM Nature of injury or illness (broken left leg, carpal tunnel left wrist, etc.) Body parts injured (Example: 2 nd /middle finger, shoulder, ankle, etc.) Left Right NA How did the injury happen? Has this claim been filed in another state? Yes No If yes, which state? Where did the injury happen? (City) (County) (State) Date of first treatment NA Clinic/h ospital name ( I f you have received treatment in more than on e location, please provide the name of clinic/hospital, treating doctor(s), address and tele phone num ber of all locations on page two or separate sheet of paper . ) Clinic/hospital mailing address (Street address, PO Box number) Clinic/hospital telephone number City State ZIP Code City State ZIP code b? Date hired (Month) (Year) Last day worked in ND prior to injury SECTION 2 Worker completion Date employer notified Person you notified Before this injury, have you had any problems, injuries, or treatment to the injured body parts? Yes No Have you missed or will you miss 5 or more consecutive days of work due to the injury? OR Has a doctor taken you off work for 5 or more consecutive days? Yes No Witness to the injury (F irst name) (L ast name) Telephone number SECTION 3 Release of information/fraud warning/signature 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, a ny 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 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 . (C ont inued on page 2) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 SFN 2828 (09/2016) C laim number (First name) (Last name) 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 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. 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 the receipt of income or an increase in income from employment, in connection benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fine s, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured workers, employers, medical providers, 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 a ccurate. Date signed In addition to myself, I authorize WSI to release information on my claim to (please print) First name Last name Relationship SECTION 4 - Employer completion Employer account number R ate class Is worker a corporate officer, owner, or family member? Yes No Mailing address (Street address, PO Box number) City State ZIP code Has the worker missed or will they miss 5 or more consecutive days of work due to the injury? OR Has a doctor taken the worker off work for 5 or more consecutive days? Yes No Date employer notified Person notified Before this injury, are you aware of the worker having any problems, injuries, or treatment to the injured body part? Y es No Unknown Do you have a Designated Medical Provider (DMP)? Yes No Did the worker add another medical provider? Yes No If yes, which provider? Do you question this claim? Yes No If yes, please explain in section 5. Title Date signed SECTION 5 Additional information or comments * In compliance with the Federal Privacy Act of 1974, disclosure of the Social Security number on this form is mandatory pursuant to N.D.C.C. 247 65-05-02. The Social Security number is used for identification and verification purposes. Failure to provide this information may result in a delay in processing your request. To report an instance of fraud, contact the ND Fraud and Safety Hotline at 800-243-3331. American LegalNet, Inc. www.FormsWorkFlow.com