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Coon Rapids Chiropractic

Coon Rapids Chiropractic

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    • Dr. Ryan Brandt
    • Dr. Jim Brandt
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Workers Compensation Injury Report

Name(Required)
Address(Required)
Gender(Required)
Employer Address(Required)
Did your Injury occur while employed elsewhere?(Required)
Employer Address(Required)

Contact Information for Worker's Comp (WC) Claim

We need copies of any Employer/Insurance workers' comp paperwork you were given.
Drop files here or
Max. file size: 4 MB.
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    Does your employer know about the accident/injury?(Required)
    MM slash DD slash YYYY
    Have you seen any other doctors/physical therapists/specialists?(Required)
    What type of doctor/provider?
    Did you receive permission from insurance to change doctors?(Required)
    Do you have a referral?(Required)
    Have you reported the accident/injury to anyone else?(Required)
    Did you obtain permission from your employer to see a doctor?(Required)
    Are you filing a claim under State or Federal Compensation Acts?(Required)
    Have you had similar problems before?(Required)
    12/10/2023
    This field is for validation purposes and should be left unchanged.

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