Client Forms | Fort Lauderdale Personal Injury Lawyers Jo Ann Hoffman & Associates

Client Forms

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Additional Client Forms

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PERSONAL INJURY FORMS

Authorization to Release Medical Information (HIPAA)
Application for No-Fault Benefits (PIP) 3 pages
Wage and Salary Verification (for earnings before accident)
Mileage Claim Reimbursement
MEDICARE Information Authorization

WORKERS’ COMPENSATION FORMS

Attestation Form for Petition for Benefits
Authorization to Release Medical Information (HIPAA)
Wage Statement for Pre-Accident Earnings
Mileage Claim Reimbursement
Statement of Charges for Drugs and Medical Supplies Reimbursement
Social Security Consent for Release of Information

DEFENSE BASE ACT AND LONGSHORE & HARBOR WORKERS’ COMPENSATION ACT

Authorization to Release Medical Information
Report of Earnings LS-200
Notice of Employee’s Injury or Death LS-201
Employer’s First Report of Injury or Occupational Illness LS-202
Employee’s Claim for Compensation LS-203
Claim for Death Benefits LS-262