Maxcis Insurance Case

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Tina Castle of Maxcis Insurance Company referred this file for medical case management. Instructions were given to meet with Manuel Zamora and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.

INTERVIEW SETTING

On 10/10/17 I met Mr. Zamora at the Saginaw Valley Walk-in Clinic. Mr. Zamora is alert and oriented. He allowed me to go back into the examination room. Mr. Zamora was very open and provided information without asking.

MEDICAL FACTORS

On 10/6/17 Mr. Zamora provided te following description of the injury on 10/10/17 he provided another telling of the injury with additional details. Mr. Zamora said while at work he was crossing a parking lot. He felt a “bump” on his leg …show more content…
Place of Employment: Saginaw Valley Ford Lincoln
• Job Title: car salesman
• Start date: 8/28/17 Stop date: current
• Hours per week: 40
• Job requirements and physical demands: sit, stand, and walk

• Laboratory work for 1.5 years
• San Antonio auto dealership for 1 year
• Saginaw Valley Ford Lincoln for 2.5 years

CURRENT EMPLOYER CONTACT INFORMATION

Ms. Castle has all contact with employer

WORKERS’ COMPENSATION HISTORY

Denied

FAMILY/SOCIAL/FINANCIAL FACTORS

Mr. Zamora reports he is staying with a friend. There is only one small step to enter the home. Mr. Zamora reports he is a Pro Wrestler and performs about 2 times a month.
Emergency Contact –he said he would provide me with a contact number.

PHYSICAL DESCRIPTION

Height: 6 foot 2 inches
Weight: 359 pounds
Hair: head shaved
Eyes: brown
Dominant hand: right

CLIENT’S FUTURE PLANS

Mr. Zamora said he would like to get rid of his pain, and go back to work.

CONSENT/EXPLANATION OF CASE MANAGEMENT

I explained my role as a medical case manager and Mr. Zamora verbalized understanding. He read and willingly signed the Authorization For Release Of Medical Information form.

ATTORNEY

Mr. Zamora denied legal representation.
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