Accident Report (Employee)

Accident LocationDewitt michigan

Districtdewitt

Supervisor NameMary .

Date of Accident12/08/2023

Time of Accident09:00 PM

Employee NameBruce Williams

Address912 andrus ave
Lansing, MIchigan 48917
Map It

Phone(810) 336-1263

Date of Birth01/28/1999

Last 4 digits of your Social Security Number1640

Do you think you need to see a doctor today?No

Description of Accident

I arrived at work to do my normal duties clean out vacuume,vacuume floors,clean tables,change trash,clean toilets, mop bathrooms. Before this incident I haven't needed an inhaler except for bronchitis. I was just cleaning a room with vacume and wiping down tables and cleaning bathroom. And all of the sudden I started coughing and my lungs started to hurt and mild chest pain. The coughing lasted about 10-15 minutes then started to settle but then my breathing became labored and it felt like I couldn't catch a full breath. So I ended up finishing my shift as normal didn't think anything much of it. Went to the store after that shift and bought an over the counter inhaler. And used it and felt better for a few hrs still thinking nothing of it. Week or 2 goes by and I still feel short of breath and coughing in the morning. Went and seen my doctor and told them what happened. This happened approximately on December 8th 2023. And it is now March 20th 2024 and I have been using an inhaler for the duration of this time. I am going to see an specialist about my condition to see if it's anything serious. Also the names of the chemicals are. Tru shot 2.0 multi surface bathroom cleaner/ disinfectant. The other chemical is tru shot restrooms cleaner. Also Tru shot power cleaner and degreaser.

What part of your body has been injured? Check all that apply
  • Head
  • Mouth

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureBruce Williams

Date03/20/2024

Accident LocationRidge wood

Districtnorthville

Supervisor NameTammy S

Date of Accident03/19/2024

Time of Accident12:15 PM

Employee NameDaneisha Moore

Address3123 Scenic Lake Dr
Ann Arbor, MI 48108
Map It

Phone(313) 550-9006

Date of Birth05/15/1998

Last 4 digits of your Social Security Number2801

Do you think you need to see a doctor today?Not Sure

Description of Accident

I don’t remember the time of the lunch but it was during lunch

What part of your body has been injured? Check all that apply
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureDaneisha moore

Date03/19/2024

Accident LocationBurger

Districtnorthville

Supervisor NameTori Morris

Date of Accident03/08/2024

Time of Accident09:00 AM

Employee NameLucas Peetz

Address32568 bridge st
Garden city, MIchigan 48135
Map It

Phone(734) 877-2528

Date of Birth03/09/2004

Last 4 digits of your Social Security Number8557

Do you think you need to see a doctor today?Not Sure

Description of Accident

My back just started to get extremely tight and I can not walk or stand up straight at all

What part of your body has been injured? Check all that apply
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureLucas peetz

Date03/08/2024

Accident Location1041 Troy Bishop Fifth Third Bank

Districtnorth_east_banks

Supervisor NameBrandy Homrich

Date of Accident03/04/2024

Time of Accident07:30 PM

Employee NameAmity Ratkus

Address107 Telford Dr
Troy, MIchigan 48085
Map It

Phone(248) 224-4069

Date of Birth05/05/1975

Last 4 digits of your Social Security Number3991

Do you think you need to see a doctor today?Yes

Description of Accident

Bending over using regular vacuum with attachment. Vacuum pulled forward and tipped due to hose recoil and landed on outer left ankle bone. Small cut. Some pain and bruising with increased swelling over last two days in foot and over outer bone. Fully functional. Moderate pain but concerned of increased swelling and discoloration.

What part of your body has been injured? Check all that apply
  • Left Ankle

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureAmity Ratkus

Date03/07/2024

Accident LocationMcGregor Elementary

Districtbay_city

Supervisor NameKaren Allore

Date of Accident02/29/2024

Time of Accident09:40 PM

Employee NameJessica Bissonette

Address918 Stanton st
Bay city, MIchigan 48708
Map It

Phone(989) 714-8779

Date of Birth04/04/2024

Last 4 digits of your Social Security Number9393

Do you think you need to see a doctor today?Yes

Description of Accident

I was on my last hallway in the Sensi room a teacher threw something heavy away as I was picking it up. It ripped the bag and fell right on my left little baby toes. I think I might’ve broke my one little toe.

What part of your body has been injured? Check all that apply
  • Left Foot

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJessica bissonette

Date02/29/2024

Accident LocationKraft meadows

Districtcaledonia

Supervisor NameKyle Anderson

Date of Accident02/27/2024

Time of Accident05:40 PM

Employee NameYesenia Arcay

Address4766 84th st SE
Caledonia, MIchigan 49316
Map It

Phone(862) 668-5158

Date of Birth01/07/1978

Last 4 digits of your Social Security Number8788

Do you think you need to see a doctor today?Yes

Description of Accident

5:30ish back by the gym Yesenia put on the backpack vac and heard a crack or pop and just thought it was age related. It hurt through out the night. Marisa saw her over the evening looking uncomfortable and trying to stretch out her shoulder. When Yesenia went to the restroom she noticed her right shoulder was lower than her left and she could not lift her arm above her head. After that Yesenia told Marisa to call me. That was at 9:33pm. She is leaving work to head to urgent care after this report is filled out.

What part of your body has been injured? Check all that apply
  • Right Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureYesenia Arcay

Date02/27/2024

Accident LocationIonia high school 1900

Districtionia

Supervisor NameKeegan Nielsen

Date of Accident02/19/2024

Time of Accident05:20 PM

Employee NameJessica Garvie

Address220 Dunham St
Sunfield, MI 48890
Map It

Phone(616) 902-7087

Date of Birth01/21/1979

Last 4 digits of your Social Security Number2324

Do you think you need to see a doctor today?Not Sure

Description of Accident

Twisted right forearm while vacuuming

What part of your body has been injured? Check all that apply
  • Right Shoulder
  • Right Wrist
  • Right Hand

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJessica Garvie

Date02/19/2024

Accident LocationHigh school 1900

Districtionia

Supervisor NameJessica Storey

Date of Accident02/19/2024

Time of Accident05:20 PM

Employee NameJessica Garvie

Address220 Dunham st
Sun field, MIchigan 48890
Map It

Phone(616) 902-7087

Date of Birth01/21/1979

Last 4 digits of your Social Security Number2324

Do you think you need to see a doctor today?Not Sure

Description of Accident

Twisted right hand forearm while vaccuming

What part of your body has been injured? Check all that apply
  • Right Shoulder
  • Right Wrist
  • Right Hand

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureKaiya hillard

Date02/19/2024

Accident LocationEllis

Districtbelding

Supervisor NameAlexis Weaver

Date of Accident02/19/2024

Time of Accident10:35 AM

Employee NameJinyka Williams

Address4454 Noddins Rd
Belding, MIchigan 48809
Map It

Phone(616) 303-9734

Date of Birth03/29/1999

Last 4 digits of your Social Security Number9395

Do you think you need to see a doctor today?Not Sure

Description of Accident

Got called for a puke clean up in the gym but wasn't told where it was in the gym. It was right in front of the door, step on it and slipped. No injures as far as tell, is currently pregnant.

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJinyka Williams

Date02/19/2024

Accident LocationDewitt ms

Districtoffice

Supervisor NameGreg Schramm

Date of Accident02/14/2024

Time of Accident10:00 PM

Employee NameMary Dolezal

Address300 western f512
Lansing, MI 48917
Map It

Phone(517) 749-3263

Date of Birth02/07/1987

Last 4 digits of your Social Security Number8288

Do you think you need to see a doctor today?No

Description of Accident

Cleaning under bleachers hit back on metal framing

What part of your body has been injured? Check all that apply
  • Middle Back
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureMary Dolezal

Date02/14/2024

Accident LocationMcGregor Mentary

Districtbay_city

Supervisor NameKaren Allore

Date of Accident02/07/2024

Time of Accident10:35 PM

Employee NameJessica Bissonette

Address918 Stanton st
Bay City, MIchigan 48708
Map It

Phone(989) 714-8779

Date of Birth04/04/2024

Last 4 digits of your Social Security Number9393

Do you think you need to see a doctor today?Not Sure

Description of Accident

I was vacuuming a classroom that got changed to a new one. The cord got stuck in the door from the vacuum. I tried to get it out. I don’t know if I tripped on the cord or the rug I fell on my left side my hip and leg is fine but the top of my foot is hurting so today is February 9 after I get out of work at 11 I will be going in to get my top of my foot checked out

What part of your body has been injured? Check all that apply
  • Left Shoulder
  • Left Wrist
  • Left Hand
  • Left Leg
  • Left Knee
  • Left Ankle
  • Left Foot
  • Toes on Left Foot

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJessica Bissonette

Date02/09/2024

Accident LocationMiddle school

Districtvicksburg

Supervisor NameDarlene Case

Date of Accident02/06/2024

Time of Accident07:45 PM

Employee NamePatrick Vanemon

Address77 Thomas st.
Centerville, MIchigan 49032
Map It

Phone(269) 858-9895

Date of Birth02/06/1959

Last 4 digits of your Social Security Number6275

Do you think you need to see a doctor today?No

Description of Accident

He said he tried over the cord to the vac pack he was in the hallway when it happened. He has a cut on his right eye. But he said the cut was already there from a accident that happened at home with his dog. He tripped over his dog at home last week on Sunday.

What part of your body has been injured? Check all that apply
  • Right Eye

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignaturePatrick

Date02/06/1959

Accident LocationGchs

Districtgarden_city

Supervisor NameTori Morris

Date of Accident02/05/2024

Time of Accident05:15 AM

Employee NameBrian Junk

Address35763 florane
Westland, MIchigan 48186
Map It

Phone(173) 430-9829

Date of Birth01/23/1959

Last 4 digits of your Social Security Number5960

Do you think you need to see a doctor today?Not Sure

Description of Accident

Moving heaven lunch room tables from sat event .

What part of your body has been injured? Check all that apply
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureBrian junk

Date02/05/2024

Accident LocationGchs

Districtgarden_city

Supervisor NameTori Morris

Date of Accident02/02/2024

Time of Accident08:00 AM

Employee NameBrian Junk

Address35763 florane
Westland, MIchigan 48186
Map It

Phone(734) 309-8290

Date of Birth01/23/1959

Last 4 digits of your Social Security Number5960

Do you think you need to see a doctor today?Not Sure

Description of Accident

Hand sanitizer got into my left eye.

What part of your body has been injured? Check all that apply
  • Head
  • Left Eye

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureBrian junk

Date02/02/2024

Accident LocationMoraine

Districtnorthville

Supervisor NameCynthia Dowell

Date of Accident01/23/2024

Time of Accident12:55 AM

Employee NameFrances Hewlett

Address25303 west nine mile rd
Southfield, MIchigan 48033
Map It

Phone(313) 932-5405

Date of Birth12/29/1956

Last 4 digits of your Social Security Number1409

Do you think you need to see a doctor today?No

Description of Accident

Slipped and fell on ice while taking trash to the dumpster at door 43

What part of your body has been injured? Check all that apply
  • Lower Back
  • Left Shoulder
  • Left Wrist
  • Left Hand
  • Left Leg

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureFrances Hewlett

Date01/24/2024

Accident LocationOn the 131 northbound between 44 and 36 street

Districtbyron_center

Supervisor NameStaci Common

Date of Accident01/19/2024

Time of Accident04:30 PM

Employee NameJolene Moore

Address950 Den Hertog
Wyoming, MIchigan 49509
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Phone(616) 893-7876

Date of Birth09/01/1977

Last 4 digits of your Social Security Number2966

Do you think you need to see a doctor today?Yes

Description of Accident

Car accident
Some hit my car on 131 on way home from work.
44 between 36 northbound 131

What part of your body has been injured? Check all that apply
  • Upper Back
  • Left Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJolene moore

Date01/23/2024

Accident LocationOn the 131 northbound between 44 and 36 street

Districtbyron_center

Supervisor NameStaci Common

Date of Accident01/19/2024

Time of Accident04:30 PM

Employee NameJolene Moore

Address950 Den Hertog
Wyoming, MIchigan 49509
Map It

Phone(616) 893-7876

Date of Birth09/01/1977

Last 4 digits of your Social Security Number2966

Do you think you need to see a doctor today?Yes

Description of Accident

Car accident
Some hit my car on 131 on way home from work.
44 between 36 northbound 131

What part of your body has been injured? Check all that apply
  • Upper Back
  • Left Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJolene moore

Date01/23/2024

Accident LocationLeonard and turner st

Districtgrand_rapids_banks

Supervisor NameShamiel Sanders

Date of Accident01/21/2024

Time of Accident08:30 PM

Employee NameShamiel Sanders

Address832 cutler st
Wyoming, MIchigan 49509
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Phone(616) 304-0771

Date of Birth08/03/1992

Last 4 digits of your Social Security Number7706

Do you think you need to see a doctor today?No

Description of Accident

Driver ran a red light and hit me on drivers side causing the car to be totaled

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureShamiel sanders

Date01/22/2024

Accident LocationHastings middle school

Districthastings

Supervisor NameAustin Hartwell

Date of Accident01/22/2024

Time of Accident09:00 PM

Employee NameAustin Hartwell

Address914 N Mason Rd
Vermontville, MIchigan 49096
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Phone(517) 667-2738

Date of Birth10/12/1998

Last 4 digits of your Social Security Number6500

Do you think you need to see a doctor today?Not Sure

Description of Accident

Overdid it and tweaked previous surgery spots. Lots of nerve pain

What part of your body has been injured? Check all that apply
  • Upper Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureAustin Hartwell

Date01/22/2024

Accident LocationHolland Language Academy

Districtholland

Supervisor NameRobert Vancent

Date of Accident01/22/2024

Time of Accident08:15 PM

Employee NameAlba Mercado

Address13637 Signature Dr.
Holland, MIchigan 49424
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Phone(616) 834-4191

Date of Birth08/20/1988

Last 4 digits of your Social Security Number2433

Do you think you need to see a doctor today?Yes

Description of Accident

I was filling up the scrubber machine when I missed a step back. When I try to balance my self I step on a machine. I felt back solid on the ground and my wrist hit the wood floor cabinet.

What part of your body has been injured? Check all that apply
  • Lower Back
  • Left Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureAlba Mercado

Date01/22/2024

Accident LocationHS 0743

Districtfremont

Supervisor Nameserina musa

Date of Accident01/11/2024

Time of Accident03:35 PM

Employee NameSerina Musa

Address174 S Benson st
PO BOX 544
White Cloud, MIchigan 49349
Map It

Phone(231) 580-7440

Date of Birth08/26/1970

Last 4 digits of your Social Security Number3499

Do you think you need to see a doctor today?No

Description of Accident

Going into the main gym for BB game setup a student Running on the track was not paying attention and ran into me knocking me down hard... I jarred my back good, I landed mostly on right knee and left wrist. My glasses flew off and my phone case was a little damaged. Mr Walls (athletic director) was notified and is looking at cameras to determine which student did it. Several students tried to help me get up, but I was able to after I scooted to the fence to help pull myself up.

What part of your body has been injured? Check all that apply
  • Lower Back
  • Left Wrist
  • Right Knee

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureSerina M Musa

Date01/11/2024

Accident LocationL3 harris

Districtl-3_communications

Supervisor NameEmma Zapata

Date of Accident01/10/2024

Time of Accident02:10 PM

Employee NameEmma Zapata

Address1910 Jerome Ave SW
Grand Rapids, MIchigan 49507
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Phone(616) 780-1410

Date of Birth07/10/1970

Last 4 digits of your Social Security Number5921

Do you think you need to see a doctor today?No

Description of Accident

I open a metal cabinet to take my purse out. When I open the door it bounce back n hit me with the corner of the door right under my left eye on the upper cheek.

What part of your body has been injured? Check all that apply
  • Left Eye

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureEmma Zapata

Date01/10/2024

Accident LocationWest Middle School

Districtportage

Supervisor NameReymundo Trevino

Date of Accident12/28/2023

Time of Accident07:20 PM

Employee NameEmma Douthat

Address1826 Charles Ave
Kalamazoo, MIchigan 49048
Map It

Phone(269) 443-9100

Date of Birth03/01/1998

Last 4 digits of your Social Security Number8700

Do you think you need to see a doctor today?No

Description of Accident

Chemical flew close to my eye but all is fine u washed it out under water.

What part of your body has been injured? Check all that apply
  • Left Eye

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureEmma Douthat

Date12/28/2023

Accident LocationNorthern High School

Districtportage

Supervisor NameReymundo Trevino

Date of Accident12/21/2023

Time of Accident11:00 PM

Employee NameReymundo Trevino

Address1918 VanZee street
Kalamazoo, MIchigan 49001
Map It

Phone(269) 929-1559

Date of Birth05/18/1987

Last 4 digits of your Social Security Number4826

Do you think you need to see a doctor today?No

Description of Accident

Removing rails from bleachers and trip and landed on my right knee

What part of your body has been injured? Check all that apply
  • Right Knee

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureReymundo Trevino

Date12/21/2023

Accident LocationLathers

Districtgarden_city

Supervisor NameLeTori Morris

Date of Accident12/21/2023

Time of Accident03:00 PM

Employee NameAndrew Taylor

Address29809 Windsor St
Garden City, MI 48135-3433
Map It

Phone(734) 897-7770

Date of Birth09/25/2021

Last 4 digits of your Social Security Number0000

Do you think you need to see a doctor today?Not Sure

Description of Accident

Fall over carpet I didn't see it in the hallway

What part of your body has been injured? Check all that apply
  • Left Knee

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureAndrew Taylor

Date12/21/2023