Lamesha Shackelford

Reliable Clinical Assistant with a background providing hands-on assistance to physicians and nurses while ensuring smooth operations at the front desk. Passionate professional with exemplary talents in taking health histories and keeping patients calm during stressful situations. Offering exemplary communication, time management and collaboration skills. Energetic professional pleasantly willing to work independently or as part of dynamic clinical team.

• SECTION 1
• TO BE COMPLETED BY THE MEMBER
• Name Jason A
• Deping Birthdate_714185 Social Security # 015 704444
• Home address (street) 15 Miller Ave (city/state) Brockton MA (zip)..2302_Home phone NIA Cell phone 508) 405-7861
• Please provide dates for the following:
• When the sickness or injury occurred 2-28-22
• When you were first disabled by this sickness or injury_3-15-22
• When y you were first treated by a clinician for this disability 3-15-22 returned to work
• O Yes No If“yes," on what date?
• Explain in detail how, when, and where this illness/injury occurred: repeat Hits to
• Both Bis toes Cauces me to walking
• Diff and iN PAR
• Happen a During the Hours of work
• Claim 2-28-22 with MÁRiquetti
• Have you
• Do you have a lawsuit, Workers' Compensation or other insurance claim pending
• Jayes Ono
• If yes, is the claim the result of OMotor Vehicle Accident Awork-Related Incident
• DOther Liability
• Member Signature
• Jouwcha
• Today's date 4,6,22
• Rev 10-2019
• Member's Name and DOB: 7-4-85 —
• SECTION 2
• TO BE COMPLETED AND SIGNED BY THE TREATING CLINICIAN-
• This is the medical doctor (MD), osteopathic physician (DO), physician's assistant (PA), nurse practitioner (NP) or licensed mental health provider treating your illness or injury
• What is the Patient's Diagnosis Code
• ICD-9: or ICD-10 [Important Note: TeamstersCare cannot process this claim without the appropriate ICD-9 Code
• U
• What is the nature of the patient's illness or injury and are there complications?
• Did the disability arise out of the patient's employment
• O Yes No
• Did the disability arise out of a motor vehicle accident
• Yes No
• If "yes,” please provide details:
• For this disabling illness/injury, on what date did you first provide medical care?
• Beyond initial care, on what subsequent dates did you see the patient
• Date
• Date
• Other dates?
• For what period has the patient been continuously disabled
• From to
• If still disabled, on what date should the patient be able to return to work?
• For: O normal duty
• Light duty
• Any restrictions?
• Why is this illness or injury preventing the member from performing their employment responsibilities?
• Please also describe the treatment plan and prognosis and include any relevant comments:
• Name (print)
• Signature (Must be signed by treating clinician only)
• Your professional designation
• Your office address (street) (town) (state) (zip)
• Your office phone number
• Your office fax number
• Today's Date
• Rev 10-2019

• Weekly Disability Claim Form Instructions (1) As the Member, you're responsible for filling out Section 1 of this Form, as well as the Authorization to Release Records. You must also have the clinician treating you for this disability fill out Section 2. Your employer must complete Section 3. (2) Mail the completed Forms along with a recent paycheck stub to: Teamsters Union 25 Health Services & Insurance Plan, Schraffts City Center
• (3) When we receive all your completed Forms and pay stub, the TeamstersCare Disability Panel will review the information you've provided to determine benefit eligibility.

CNA - Certified Nursing Assistant