John F. Perry, MD - Orthopedic Surgeon | Elverson, PA

Orthopedic Surgery and Sports Medicine

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Work injury claim form

Whether you are seeing Dr. Perry due to a worker's compensation claim or because of a motor vehicle accident, please bring the following items with you to your appointment:

•  Completed New Patient Registration forms

•  Insurance card and photo ID. (We request that you provide us with your personal health insurance information and proper referrals. In the event that your worker's compensation claim is deemed not work related or your auto claim limits become exhausted, you will be responsible for all fees for services.)

•  Referral from your primary care provider (if required)

•  X-rays, MRI's or other diagnostic studies taken within the previous six months. We ask that you please bring the actual films or CD.

•  List of current medications and medical conditions.

 

Please note that we do not accept letters of protection from your attorney for legal cases.

For worker's compensation

If you are scheduling an appointment as a result of an injury that occurred at work, you will need to provide the following information when scheduling:

•  Date of injury

•  Name of employer, contact name and telephone number

•  Name of the insurance carrier covering the claim and the claim number

•  Accepted injury

For motor vehicle accidents

If you are scheduling an appointment as a result of an injury sustained in an automobile accident, you will need to provide the following information at the time you call for an appointment:

•  Date of accident

•  Name of insurance carrier covering your claim, as well as the contact name and telephone number of the person representing your insurance company

•  Claim number

 

If you do not obtain the needed referrals, and your auto claim becomes exhausted, you risk not being covered by your personal health insurance and will be responsible for the payment of the unpaid bills.

Offices available

in Pennsylvania

and Florida.

Work injury claim form