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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