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Forms


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Request for Appointment of Limited Representative for Claimant

Use this form if you wish to allow your personal health information with regards to your workers' compensation or personal injury protection claim to be disclosed to a limited representative.

ID: 32434 (0519)


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Procedure/Surgery and After Care Pre-Certification

This form is used to request authorization to perform medical procedures /surgeries. Physicians are required to fill out the form and fax it to the assigned case manager along with the applicable medical documentation to support medical necessity.

ID: 32442 (0521)


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Workers’ Compensation Patient Treatment Plan Form

The Workers’ Compensation Patient Treatment Plan Form serves as a summary of a workers’ compensation patient’s: medical status; treatment plan; anticipated return-to-work date for temporarily modified, full duty and permanently modified work; and maximum medical improvement status. Please indicate the projected return-to-work date on the Patient Treatment Plan Form, accompanied by the required restrictions. The assigned case manager will then work with the employer to determine if the employer can accommodate the restrictions.

This form must be faxed to the assigned case manager within one business day of the office visit. Chart notes and/or lab or diagnostic test results must be faxed to the assigned case manager the same day of the office visit or the next business day.

ID: 0533 (0719)


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Workers’ Compensation Physical Demands Analysis Form

When applicable, the case manager will provide physicians with a Workers’ Compensation Physical Demands Analysis Form that has been completed by the employer. This form will outline the injured workers’ job duties. Many employers have modified or alternative job assignments of which you and the employee may not be aware.

ID: 32265 (W0719)


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Weekly Physical/Occupational Therapy Plan Form

This form provides HCS workers’ compensation case manager with documentation of the patient’s functional progress and the therapist’s subjective and objective assessment findings along with his/her recommendations and future treatment plan.

This form must be faxed to the assigned case manager by the end of every week during the course of the patient’s therapeutic treatment.

ID: 32267 (W0719)


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Progress and Treatment Status Psychologist/Psychiatrist Report

This form is used by psychologists and psychiatrists to document a workers’ compensation patient’s medical assessment, treatment plan and estimated return-to-work date.

This form must be faxed to the assigned case manager within one business day of the office visit.

ID: 32266 (W0719)


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HCS Electronic Transaction Authorization Form

If you are interested in becoming a trading partner with Horizon Casualty Services, please complete this form.

ID: 32440 (0919)