Online Records Request Form
|
WORK COMP |
PI |
LTD/SSA |
DIVORCE |
ADA/EEOC |
|
|
Client's Current Address, Phone & E-mail |
x |
x |
x |
x |
x |
|
First Report of Injury |
x |
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|
Average Weekly Wage Calculations |
x |
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|
Personnel or Other Employment Records |
x |
x |
x |
x |
x |
|
Resume |
x |
x |
x |
x |
x |
|
Deposition |
x |
x |
x |
x |
x |
|
Answers to Interrogatories |
x |
x |
x |
x |
x |
|
Physicians Reports/Office Notes |
x |
x |
x |
x (if applicable) |
x (if applicable) |
|
Functional Capacity Evaluation |
x |
x |
x |
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|
Physical Therapy/Occupational Therapy Reports |
x |
x |
x |
||
|
Hospital Admitting & Discharge Summaries |
x |
x |
x |
||
|
High School/College Transcripts |
x |
x |
x |
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|
Vocational Reports and/or Testing |
x |
x |
x |
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|
Income Tax Returns w/W-2’s (Preferably 4 years prior to accident date and subsequent to accident.) |
x |
x (or SSA earnings) |
x |
x |
|
|
Accident Report |
x |
x |
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|
Ambulance Report |
x |
x |
