Physicians Report On Injury In Lieu Of Testimony

Please return BLUE form to Criminal Injuries Compensation Fund, Post Office Box 26927, Richmond, Virginia, 23261 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 Yes Have charges been filed for payment with anyone (other than CICF)? No 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. 10/05 American LegalNet, Inc. www.FormsWorkFlow.com