Magenda MD | Proceeding
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Claimant Information:
Claimant:
First Name
*
:
Middle Name :
Last Name
*
:
Date Of Birth :
Date Of Accident :
WCB# :
Claim# :
Gender:
Male
Female
N/A
SLU
Claim Type:
Workers Comp
No Fault
Labor Law
Slip and Fall
Subbed
//
Lien
Providers:
-Select-
Joshua Bonsell
GLENN BABUS
M. MORAL
Adrien St. Ange
Joshua Persaud
David Basch
Javier Motta
S Kaufman
Kevin Cousins
Ardian Tapija
Yakov Yakubov
William Flores
Paul-Marie Brisson
Sophia Solomon
Moral Muhammad
Jean Pierre Louis
Jacob Peacock
Mohammad Moral
Iyrina Gerashenko
Martin Quirno
Brian Dawson
Catherine Ellis
Juan Robles
Matthew Wert
Tim Lopresti
Interventional NJ
Shmuel Kaufman
Sina Menashehoff
Robert Drazic
Locations:
Claimant Address:
Address Line 1:
City:
State:
ZIP/Postal Code:
Phone 1:
Phone 2:
Insurance Company:
Company Name:
Idaho Falls Downtown Development Corporation
LIEN
Insurance Company:
Address Line 1:
Address Line 2:
Country:
City:
State:
ZIP/Postal Code:
Phone 1:
Ext
Phone 2:
Fax:
Email:
Attorney Information:
Attorney:
Law Firm:
Phone Number:
Magenda MD | Proceeding
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Document Type
*
:
INITIAL
FOLLOW-UP
POST-OP
PRE-OP
OPERATIVE REPORT
INJECTION
Post Op Follow Up
SLU 4.3 Form
C3 Form
MRI Report
Surgery Right Knee
Surgery Left Knee
Surgery Right Shoulder
Surgery Left Shoulder
Surgery Right Wrist
Surgery Left Wrist
Surgery Right Ankle
Surgery Left Ankle
Providers
*
:
-Select-
Joshua Bonsell
GLENN BABUS
M. MORAL
Adrien St. Ange
Joshua Persaud
David Basch
Javier Motta
S Kaufman
Kevin Cousins
Ardian Tapija
Yakov Yakubov
William Flores
Paul-Marie Brisson
Sophia Solomon
Moral Muhammad
Jean Pierre Louis
Jacob Peacock
Mohammad Moral
Iyrina Gerashenko
Martin Quirno
Brian Dawson
Catherine Ellis
Juan Robles
Matthew Wert
Tim Lopresti
Interventional NJ
Shmuel Kaufman
Sina Menashehoff
Robert Drazic
Location:
Visit Date
*
:
File
*
:
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Description:
Note:
Send Document to Complete Report:
Magenda MD | Proceeding
×
Claimant Information:
Claimant:
First Name
*
:
Middle Name :
Last Name
*
:
Date Of Birth :
Date Of Accident :
WCB# :
Claim# :
Gender:
Male
Female
N/A
SLU
Claim Type:
Workers Comp
No Fault
Labor Law
Slip and Fall
Subbed
//
Lien
Providers:
-Select-
Joshua Bonsell
GLENN BABUS
M. MORAL
Adrien St. Ange
Joshua Persaud
David Basch
Javier Motta
S Kaufman
Kevin Cousins
Ardian Tapija
Yakov Yakubov
William Flores
Paul-Marie Brisson
Sophia Solomon
Moral Muhammad
Jean Pierre Louis
Jacob Peacock
Mohammad Moral
Iyrina Gerashenko
Martin Quirno
Brian Dawson
Catherine Ellis
Juan Robles
Matthew Wert
Tim Lopresti
Interventional NJ
Shmuel Kaufman
Sina Menashehoff
Robert Drazic
Location:
Claimant Address:
Address Line 1:
City:
State:
ZIP/Postal Code:
Phone 1:
Phone 2:
Insurance Company:
Existing Insurance Company:
Idaho Falls Downtown Development Corporation
LIEN
Insurance Company:
Address Line 1:
Address Line 2:
Country:
City:
State:
ZIP/Postal Code:
Phone 1:
Ext
Phone 2:
Fax:
Email:
Attorney Information:
Attorney:
Law Firm:
Phone Number:
Magenda MD | Work
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Total disability means the injured worker cannot work in any capacity.
Marked disability (75%) means the injured worker is limited to sedentary work.
Sedentary work means desk work with sitting most of the time.
Moderate disability (50%) means the injured worker is limited to light work.
Mild disability (25%) means the worker can perform heavier work, however with some restrictions.
Magenda MD | Proceeding
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Case #
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Claim Type
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Magenda MD | Documents
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Case #
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Claim Type
Date Of Accident
WCB #
Visit Date
Document Type
Physician
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Magenda MD | Proceeding
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Claimant Information:
Claimant:
Name Of Patient
*
:
Please enter Patient Name
Provider
*
:
-Select-
Joshua Bonsell
GLENN BABUS
M. MORAL
Adrien St. Ange
Joshua Persaud
David Basch
Javier Motta
S Kaufman
Kevin Cousins
Ardian Tapija
Yakov Yakubov
William Flores
Paul-Marie Brisson
Sophia Solomon
Moral Muhammad
Jean Pierre Louis
Jacob Peacock
Mohammad Moral
Iyrina Gerashenko
Martin Quirno
Brian Dawson
Catherine Ellis
Juan Robles
Matthew Wert
Tim Lopresti
Interventional NJ
Shmuel Kaufman
Sina Menashehoff
Robert Drazic
Please enter Provider
Visit Date
*
:
Please enter Visit Date
Document Type
*
:
INITIAL
FOLLOW-UP
POST-OP
PRE-OP
OPERATIVE REPORT
INJECTION
Post Op Follow Up
SLU 4.3 Form
C3 Form
MRI Report
Surgery Right Knee
Surgery Left Knee
Surgery Right Shoulder
Surgery Left Shoulder
Surgery Right Wrist
Surgery Left Wrist
Surgery Right Ankle
Surgery Left Ankle
Please enter Document Type
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