Nurse Value, Inc.
Case Management
 Life Care Planning
 Medicare Set-Asides

Fill out this form with as much information as possible to initiate a case.

Insured Person
Name:
Date of Birth
Address:
City, State:
Zip Code:
Phone:
Mobile Phone:

Insurance

Employer
Contact Name:
Address:
City, State:
Zip Code:
Phone:
Mobile Phone:
Email Address:

Accommodated Work Available?
Yes No
 

Claim Information
Diagnosis:
Date of Injury/Illness:
Claim Type :
Workers' Comp Auto
Disability Status:
Jurisdiction of Claim(State):
Claim Number:
 

Treating Provider(s)
Name (Primary):
Specialty:
Address:
City, State:
Zip Code:
Phone:
Fax:
Email:
   
Name (Secondary):
Specialty:
Address:
City, State:
Zip Code:
Phone:
Fax:
Email:
 

Referral Company (For Invoicing Purposes)
Contact Name:
Address:
City, State :
Zip Code:
Phone:
Mobile Phone:
Fax:
Email:
   

Defense Attorney
Name:
Address:
City, State :
Zip Code:
Phone:
Mobile Phone:
Fax:
Email:
 

Plaintiff Attorney
Name:
Address:
City, State :
Zip Code:
Phone:
Mobile Phone:
Fax:
Email:
   

Services Requested (Select more than one if needed)

Life Care Plan

•   Call Nancy Davis at 217-947-2219 to discuss specific needs
Medicare Set Aside Allocation
•   Call Nancy Davis at 217-947-2219 to discuss specific needs
Telephonic Case Management
•   Medical release of information if available
• Medical records to date
Field Case Management
•   Medical release of information if available
• Medical records to date
Task Assignment
•   Call Nancy Davis at 217-947-2219 to discuss specific needs
Medical Record Review
 

Nurse

Like Medical Provider
 
•   All medical records available
• Medical release of information if available
Cost Projection
•   All Medical records available pertaining to specific request
Other
 

Specific Instructions
 

 

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