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Macias Consulting Services

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MELINDA MACIAS CONSULTING

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Leno & Associates

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CONTACT INFORMATION

 


Services Requested:
Temporary Modified/Alternative Offer
Regular Work Offer
Permanent Modified/Alternative Offer
Job Description (Usual & Customary Position)
Onsite Job Analysis
Obtain Physician Return-to-Work Form - DWC AD 10133.36
Early Contact: Employer & Physican - Attach & Provide 5020 Injury Report
Other/Explanation:

Fax or E-mail job description of the usual and customary occupation if available or indicate a request to draft one.
Fax or E-mail report confirming permanent or temporary work restrictions if available.
Fax or E-mail Physician Return-to-Work Form (DWC AD 10133.36) if available.

Claimant Information
Claim Number:
  
Claimant Name:
 Telephone:
Street Address:
City: State: Zip:
Date of Birth:
 Occupation at Date of Injury:
Date of Injury:

Specific       CT

 AWE/Wages:
Injury/body part:
 Date of Hire:
Employer Contact Information
Employer:
 Telephone:
Contact person:
 Fax:
Street Address:
City: State: Zip:
Claims Professional Information
Claims Professional:
 Telephone:
Street Address:
City: State: Zip:
E-mail:
 Fax:
Firm:
 Date of Referral:
Applicant Attorney Information
Attorney Name:
 Telephone:
Address:
City: State: Zip:
Treating Physician Information
Treating MD:
 Telephone:
Street Address:
City: State: Zip:
P & S?    Yes - Date:     No
Last Appt. Date:
 Next Appt. Date:
Other Provider (AME, QME)
Other Provider:
 Telephone:
Street Address:
City: State: Zip:
P & S?    Yes - Date:     No
Work Restrictions
 

Defense Attorney Information - Special Instructions
 
Please Enter Dates:
Date RTW temporary mod/alt duties:
Date RTW permanent mod/alt duties:
Date last T.D. was paid through (DOI'S 2004 to 2012):
Physicians Return-to-Work Form (DWC AD 10133.36) Received: Yes - Date:     No
Clerical Contact Name and Number:
Contact Information:
CLAIMS ASSISTANT OR CLERICAL CONTACT NAME:
CLAIMS ASSISTANT OR CLERICAL CONTACT NUMBER:

           

Office:  1-626-422-4403 / Fax:  1-626-227-0777  Email:  Melinda@maciasconsultingservices.com

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