WORKER'S COMPENSATION ASSIGNMENT OF BENEFITS FORM
Hasib Mikael Sarij, M.D.
1111 Broad Hollow Rd. (Route 110) Unit 114 Farmingdale, NY 11735
2080 Deer Park Ave Deer Park, NY 11798
Tel: (516) 336-8659 • 631-270-7733 / Fax: (516) 584-0055
Email address *
Full Name *
Today's Date *
I authorize Integrated Spine & Pain Care to release medical records to my attorney as requested.
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Date of Birth *
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S.S. Number
WCB Number
Carrier Case
Date of Injury
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Place of Injury
Employer
Address
Phone Number
Insurance Carrier
Address:
Phone Number
Adjuster Name
Phone Numer
Fax Number
Injured Body Area
Lawyer's Name
Lawyer's Address
Lawyer's Phone Number
Signature (Print Full Legal Name) *
I authorize the office of Dr. Hasib Sarij to release medical records to my attorney as requested.
Today's Date *
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