Fill and Sign the Export Certifying a Class Action Form

I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' comp ensation fraud, upon conviction, shall be guilty of a felony. TREATING PHYSICIAN’S REPORT AND NOTICE OF TREATMENT FILE NO. (Must be filled out) State Law requires the Treating Physician to supply the injured employee, the employer and the employe r's insurer with a full examining report of injuries found at the time of t he examination and proposed treatment. This report must be supplied within seven (7) days after the examination. Also, at the concl usion of the treatment, the Treating Physician shal l supply a full report of treatment to the employer of the injured employee.
         
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This space for Court Use only In re claim of: Full Name of Injured Employee (Claimant) Claimant’s Social Security Number Name of Employer (Respondent) Employer’s Insurance Carrier, Permit # for Court Ap proved Individual Self-Insured or Own Risk Group, Uninsured (Please type or print) 1. HISTORY OF ACCIDENT : Date and Time of Accident Occupation or job of employee State, in the employee’s own words, how the acciden t occurred. Were the employee’s injuries causally connected to the above described accident? 2. MEDICAL HISTORY Age Date of birth State the objective complaints of the employee. State whether previous sickness or injury contribut ed to the employee’s present condition. List all other treating or consulting physicians. Were medical records reviewed? 3. CLINICAL EVALUATION : Describe your examination and all diagnostic tests performed. State your findings and diagnoses. Describe the medical treatment you recommend for th e future. 4. EVALUATION OF TEMPORARY TOTAL DISABILITY : Date of employee’s first treatment by you. State the date you released the employee as able to return to work. Has the employee been totally unable to return to w ork for any period? Employee was temporarily totally disabled from: Is the employee’s inability to work the result of the above described accident? Address (Number and Street) I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employee
Employer
Insurance Carrier City State Zip Code 2/06 Signed this ____________ day of _________________, ________ Address Type or Print Name of Treating Physician Signature of Treating Physician City State Zip Code (Please type or print ) Was the employee hospitalized? Other significant medical history of the employee. Describe the medical treatment rendered to date.