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Completing the accident report
(Report of Industrial Injury or Occupational Disease)
To speed up the claim process, make sure the accident report is:
Filled out completely, leaving areas blank may delay processing of the claim and your bills. If the condition is a disease, enter "N/A" for "not applicable" in both of the following boxes:
- Date of injury.
- Time of injury.
As specific as possible.
- Include a complete diagnosis and appropriate Common Diagnostic Codes (ICD-9 codes). Clarify a specific body site and the definition of the injury.
- If your patient is unable to perform any work due to the injury or disease, estimate how much time the injured worker will lose due to the injury.
Signed by both you and your patient.
Submitted promptly with copies of the:
- History and physical,
- Emergency room evaluation, or
- Your office notes.
Consider contacting the employer
- If you have questions or concerns about the relationship between an exposure and the illness being treated.
- To request material safety data sheets (MSDS).
- To walk through the job site.
See Billing L&I for information on reimbursement.
