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	Fields denoted with a * indicate a required field. Law Firm * Type Of Case Workers' Comp    Auto Accident    Liability Attorney's Name * Attorney's E-Mail * Paralegal * Sal. Mr. Mrs. Ms. Dr. First * Last * SSN# - - D.O.B. (mm/dd/yyyy) / / Accident Date (mm/dd/yyyy) / / *If a patient is coming in for a Disability Rating, it is recommended that the date of accident must be at least 6 months old Street Apt Home Phone - - City   Cell Phone - - State ZIP Work Phone - - Office Annapolis Baltimore Work Rehab Belvedere Square Box Hill Catonsville Columbia Dundalk Edgewood Edmondson Elkton Erdman Essex Fallston (Dr. Reischer) Franklin Square Glen Burnie Glen Burnie (Dr. Reischer) Harford County ASC North Charles Overlea MRI Overlea Patterson Randallstown Severna Park Westminster White Marsh Woodholme Date * (mm/dd/yyyy) / / Time * (hh/mm) : AM PM *Please wait for a confirmation before notifying the patient Insurance Type Workers' Comp    PIP    LIABILITY Insurance Company Claims Adjuster Phone No. - - Billing Address City State ZIP Insurance Company Phone Number - - Billing Address City State ZIP *Employer at Time of Injury Employer's Name Contact Person Phone Number - - Address City State ZIP Was patient seen at a Hospital? Yes    No If yes, where: Were X-Rays taken? Yes    No If making appointment for Disability Rating or Independent Medical Evaluation, are X-Rays or Medical Records available? Yes    No *If a patient is coming in for a Disability Rating, the patient will not be scheduled if we do not receive medicals or if the date of accident is not in the last 6 months Injured Area(s) Additional Notes *Please have client bring his/her driver's license and all private insurance cards to scheduled appointments *If client is a minor they must have a parent or legal guardian present for the first visit * An e-mail with the entered informaiton will be sent immediately to the Scheduling Department of MSHC. You will receive a confirmatory email or phone call shortly if submitted during business hours, or the next business day if submitted after hours.
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