Work Comp Appointment Follow-Up Employee(Required)Select NameAbigail PeeryAlicia HerbstAllie KisterAllison McAteeAlyssa ZahnAmanda CaldwellAndrew FaulknerAndrew SniderAndrew WeaverAriel GrayArika BallengerAshley BeardBrad HahnBrad WeissBreanna BensonBrett HortonBrianna AsherBrooke NicholsBryce StewartCaleb GoveroChealsa LongChloe MoonChloe RoachChristopher HooverClayton MollColin HedrickDale HamptonDale WhitenerDaniel KempDanny ParishDavid StarkDawson KoenDerrick CarltonDustin TateDylan RiceEllen MurphyEmily GrassEmily HerbstEmily SchumerEmma CollinsErika RobinsonHaley WeberHalle ArbeitmanJacob GoodeJackie WagganerJason DossJason NoelJason SitzesJeanne HochstatterJenna BoyerJennifer PriceJessica ChitwoodJessica SagoJohn ColwellJorden FliegJoseph StepputatJoseph WingbermuehleJosh AkersKathrine DonaldsonKatie ShawKelleeta WisdomKent ColemanKevin MeseyKimberly FeldhakeKristin MotsingerKristy HalterKurtis StevensKyla NicholsKyle GartnerKylie WoffordKyleigh PrzygodaLaurine DennisLeah CoppawayLeah ThomasLewis MillerLillian SmithLucas KramerMaddy GartnerMaria JonesMarie BethelMark EarnestMatthew EggersMatthew McElrathMatthew PeeryMatthew ShortMichael PolitteMichael DodsonNathan StaffordNicholas MillsNick JenningsPaige ClarkPhillip SchiffmanRandell HeadyRebecca MillerReece KreitlerReese GibsonRenee McClureRiley ColemanRoger StevensRyan HillSamantha FrascaSamuel HerbstSarah SundhausenStefanie TalarskiSteven DickeyTamera KahlerTammy ZookTanner SundhausenTaylor CopelandTeralyn CoxTerry LeachTiffany HensonToby BrownTrina SchmitzZackary ShoemakerZach BrooksZachary Gallaher This field is hidden when viewing the formEmployee EmailDate of Original IncidentIf known — helps link this follow-up to the original report. MM slash DD slash YYYY Date of Appointment(Required) MM slash DD slash YYYY Follow-Up Type(Required) Doctor Visit Imaging (X-ray, MRI, CT, etc.) Lab Work Physical Therapy Specialist Consultation Surgery / Procedure Independent Medical Evaluation (IME) Other Provider / Facility Name(Required)Location of Appointment(Required)City and address or clinic name.Appointment Outcome(Required)Summarize the visit: diagnosis, treatment provided, recommendations, next steps.Work Status After Appointment(Required) Released to full duty Light duty / restrictions Off work No change Restrictions / Limitations(Required)List any work restrictions provided by the provider.Expected Return-to-Work Date(Required) MM slash DD slash YYYY Will you have additional appointments for this claim?(Required) Yes No Unknown at this time Next Appointment Date(Required)If known. MM slash DD slash YYYY Next Appointment Type / Provider(Required)If known.Upload DocumentsVisit summaries, work status notes, imaging reports, prescriptions, receipts, etc. Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, heic, Max. file size: 128 MB, Max. files: 10. Notes / Additional Comments
