Schedule a Workers’ Compensation Appointment

Quickly and easily request a Workers' Compensation appointment with our team. You can either call to schedule (727)-787-5577 (EXT 230) or fill out the form below and our Workers' Compensation team will contact you as soon as possible.

(Items marked with a * are required.)

(If other)

Patient Information

First Name*

Last Name*

Date of Birth*

Email Address*

Street Address*

Address Line Two*

City*

State/Province/Region*

Postal/Zip Code*

Country*

Home Phone Number*

Work Phone Number*

Employer Name*

Workers' Compensation Carrier Information

W/C Company*

Phone Number*

Fax Number*

Address*

Address Line Two*

City*

State/Province/Region*

Postal/Zip Code*

Country*

W/C Ins. Co. Billing Address (if different than above)

Address

Address Line Two

City

State/Province/Region

Postal/Zip Code

Country

Claim Number*

Is this a Florida claim?*YesNo

Adjuster Information

Adjuster*

Adjuster Phone*

Adjuster Fax*

Adjuster Email*

Nurse Case Manager Information

Nurse Case Manager*

Nurse Case Manager Phone*

Nurse Case Manager Fax*

Nurse Case Manager Email*

First Report of Injury

Has more than one area of the body been injured?*YesNo

Date of Injury*

Area of body injured*

Specific Area of the Injury*

Another area of the body injured?*

Any fractures or lacerations?*YesNo

Did the patient go to the emergency room or have any previous treatment?*YesNo

Can the patient reschedule appointments?*YesNo

Are DME items of less than $200.00 authorized?*YesNo

Injections authorized?*YesNo

Does the patient require a certified translator?*YesNo

Has the patient been seen by a specialist for this condition before?*YesNo

How was the patient injured?*

Appointment Information

Physician Requested*

Select Location*

You can email medical records, diagnostic reports, or first reports of injury.

Email your documents to our office at: fsosmworkcomp@floridaortho.com

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