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FORMS

Intake Form Instructions for New Clients

  • For each form click “View/Download”. Form will pop up in a new browser tab or window.
  • Complete each form. Save/download to your computer.
  • After all forms completed, 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:

  • Drop files here or
    Accepted file types: pdf, zip, doc, docx, jpg, jpeg.
  • This field is for validation purposes and should be left unchanged.