FORMS
Intake Form Instructions for New Clients
- For each form click “View/Download”. Form will pop up in a new browser tab or window.
- Save/download to your computer.
- For Mac users with Safari, in top browser menu choose File>Save As or Command-S on your keyboard.
- Find the form on your desktop, downloads folder, or wherever you saved it on your computer.
- Complete and save each form using Adobe Acrobat. If you do not have Acrobat, it is free to download here.
- After all forms completed and saved, use submit form at page bottom to send them.
Fill out form C-3
- Please answer all questions to best of your knowledge
- If you do not know an answer, leave it blank
- Call the office at 718-261-0800 if any trouble filling out the form
- If you answered ‘Yes’ to question 5 on page 2 – you have prior injuries to the same body part, then please fill out and sign page 3
Sign on the bottom of page 2 where it says ‘employee’s signature’
- signature can be physical or electronic signature
- if unable to sign, contact the office
Fill out form OC-400 (this is the Retainer)
- Fill out just top parts – put in your WCB number if you have one, social security number and date of accident
- Next to claimant please print your name and address
- Next to employer please print the name and address
- If you know the insurance carrier, please print name and address. Otherwise leave blank
Sign next to where it says ‘claimant’s signature’
- signature can be physical or electronic signature
- if unable to sign, contact the office
Fill out form HIPPA
- Fill out the information in the boxes at top
- Print your name where else asked
- Leave health provider’s name blank
Sign at the bottom
- signature can be physical or electronic
Fill out form Acknowledgement
- Fill out your name and address at top
- Leave blank DOA and file number
- Fill out your name in blank space after ‘I’
Fill out your name again at bottom and sign above it
- signature can be physical or electronic
After you complete all forms, submit them using the form below:
