[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-337172-105":53,"doc-detail-337172-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","notice-to-medical-providers-work-related-injury-form","Notice to Medical Providers - Work-Related Injury Form","","This document serves as an official notice and authorization form for medical providers regarding employees who have sustained work-related injuries or illnesses. It provides necessary information for the initial medical treatment, including employee details, production company context, and injury specifics. The form establishes a communication channel between the employer, the medical provider, and the claims administrator, Sedgwick. It also provides essential instructions for submitting medical invoices and work status reports to ensure proper claims processing and administrative compliance.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/notice-to-medical-providers-work-related-injury-form/337172/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/notice-to-medical-providers-work-related-injury-form/337172.png","ImageObject",442,249,{"name":88,"@type":89},"Sophia Brooks","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-21",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who is the administrator for the Workers' Compensation claims mentioned in the document?","Question",{"text":109,"@type":110},"Sedgwick is the administrator for the Workers' Compensation claims.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Where should medical invoices be submitted?",{"text":114,"@type":110},"Medical invoices should be submitted to Sedgwick at their address in Lexington, KY.",{"name":116,"@type":107,"acceptedAnswer":117},"What information must be included about the injured employee?",{"text":118,"@type":110},"The form requires the employee's name, SSN, date of injury, occupation, incident location, and the specific body parts injured.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},337172,1790670491,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962084925636,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Notice to Medical Providers  \nProduction/Event Employer: Please complete the following and fax to the physician prior to the first medical treatment visit for an employee’s work-related injury/illness.  \nNote to Physician/Medical Provider: The injured worker listed below has been referred to your office for initial medical treatment of an injury/illness that may be work-related. Sedgwick is the administrator for Workers’ Compensation claims. Please note that a claims examiner from Sedgwick must approve any non-emergency treatment following this visit.  \nEmployee  \nName:    \nSSN:    \nDate of Injury:    \nOccupation:    \nIncident Location:    \nProduction/Event Company  \nProduction/Event Name:    \nProject/Event Name:    \nContact Name:    \nTitle:    \nPhone:    \nBody Part(s) Injured:    \nEmployer/Supervisor Signature:  Today’s date:   \nSubmit medical invoices to: Sedgwick  \nP. O. Box 14440 Lexington, KY 40512-4440  \nSubmit work status’ to: Cast & Crew Entertainment  \n2300 W. Empire, 5th Floor Burbank, CA 91504  \nPh: 818.848.6022 / Fax: 818.848.4614  \nworkcomp@CastandCrew. com  \nThis does not guarantee that benefits will be payable under Workers ’ Compensation coverage. Benefit payments are always subject to a determination by the claims examiner atthe time the service was rendered.  \nThe information contained in this message may be legally privileged and confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this fax is strictly prohibited. If you have received this fax in error, please immediately notify the sender.","cbCaiiJGSphF6O5q","https://ap.wps.com/l/cbCaiiJGSphF6O5q","pdf",634707,"English","# Notice to Medical Providers\n## Employee and Incident Details\n## Production and Employer Information\n## Submission and Administrative Instructions","[{\"question\":\"Who is the administrator for the Workers' Compensation claims mentioned in the document?\",\"answer\":\"Sedgwick is the administrator for the Workers' Compensation claims.\"},{\"question\":\"Where should medical invoices be submitted?\",\"answer\":\"Medical invoices should be submitted to Sedgwick at their address in Lexington, KY.\"},{\"question\":\"What information must be included about the injured employee?\",\"answer\":\"The form requires the employee's name, SSN, date of injury, occupation, incident location, and the specific body parts injured.\"}]","Notice to Medical Providers - Work-Related Injury Form | PDF",1790018007]