Assignment Sheet Form
Your Name:
Your Email:
Your Address:
Your Phone:
Insured:
Claim Number:
Date of Injury:
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Claimant Address:
Claimant Phone:
Case Type:
Medical Negligence
Workers' Compensation
Personal Injury
Other:
Assignment Information
Assignment
Due Date
Medical Case
Management
January
February
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December
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Organize Medical
Records
January
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December
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Copy Medical
Records
January
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December
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Return Copy
to Adjuster
# Copies
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Copy for
Experts
# Copies
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Chronology of
Medical Records
January
February
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Analysis of
Medical Issues
January
February
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October
November
December
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Prepare Questions
for Staff
Interviews
January
February
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October
November
December
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Assist with/or
Conduct
Interviews
January
February
March
April
May
June
July
August
September
October
November
December
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Obtain Expert
Reviews
(standard of
care/causation)
January
February
March
April
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August
September
October
November
December
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Medical
Information
RE:
January
February
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Life Care
Plan
January
February
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November
December
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Other
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Anticipated
Assistance
and
Desired
Outcome
Claim
Concerns
Other
The Medical Resource Network, Inc.
10725 SW Barbur Boulevard, Suite 200
Portland, OR 97219
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