5021 Details

Form 5021, "Information Return by a U.S. Person With respect to a Foreign Partnership," is an Internal Revenue Service (IRS) form used to report information about foreign partnerships to the IRS. The form must be filed by any U.S. person who is a partner in, or has an ownership interest in, a foreign partnership. The information reported on Form 5021 includes the name and address of the foreign partnership, the taxpayer identification number(s) of all U.S. partners or owners, and other information requested on the form. Penalties may be assessed for failure to file Form 5021 or for filing incomplete or inaccurate information on the form. If you are a U.S.

You will discover additional information concerning the form 5021 by checking out the table we put together for you.

QuestionAnswer
Form NameForm 5021
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names5021, doctors first report, california form injury, doctor report

Form Preview Example

STATE OF CALIFORNIA

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS

Within 5 days of your initial examination, for every occupational injury or illness, send tow copies of this report to the employer's workers' compensation insurance carrier or the insured employer. Failure to file a timely doctor's report may result in assessment of a civil penalty. In the case of diagnosed or suspected pesticide poisoning, send a copy of the report to Division of Labor Statistics and Research, P.O. Box 420603, San Francisco, CA 94142­0603, and notify your local health officer by telephone within 24 hours.

1. INSURER NAME AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE DO NOT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USE THIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COLUMN

2.

EMPLOYER NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Address

No. and Street

 

 

 

 

 

City

 

Zip

 

 

 

Industry

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Nature of business (e.g., food manufacturing, building construction, retailer of women's clothes.)

 

 

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

PATIENT NAME (first name, middle initial, last name)

 

 

 

 

6. Sex

 

 

7. Date of

Mo.

Day

Yr.

Age

 

 

 

 

 

 

 

 

 

 

 

D Male D Female

 

Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Address:

No. and Street

 

 

City

Zip

 

 

 

 

9. Telephone number

 

 

 

Hazard

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Occupation

(Specific job title)

 

 

 

 

 

 

 

 

 

11. Social Security Number

 

 

Disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

­

­

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Injured at:

No. and Street

 

 

City

 

 

 

County

 

 

 

 

 

 

Hospitalization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Date and hour of injury

Mo.

Day

Yr.

 

Hour

 

 

 

 

14. Date last worked

Mo.

Day

Yr.

Occupation

 

 

or onset of illness

 

 

 

 

a.m.

 

 

 

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Date and hour of first

Mo.

Day

Yr.

 

Hour

 

 

 

 

16. Have you (or your office) previously

Return Date/Code

 

 

examination or treatment

 

 

 

 

a.m.

 

 

 

p.m.

 

treated patient?

D Yes

D No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient please complete this portion, if able to do so. Otherwise, doctor please complete immediately, inability or failure of a patient to complete this portion shall not affect his/her rights to workers' compensation under the California Labor Code.

17.DESCRIBE HOW THE ACCIDENT OR EXPOSURE HAPPENED. (Give specific object, machinery or chemical. Use reverse side if more space is required.)

18.SUBJECTIVE COMPLAINTS (Describe fully. Use reverse side if more space is required.)

19.

OBJECTIVE FINDINGS (Use reverse side if more space is required.)

 

 

 

 

 

 

A. Physical examination

 

 

 

 

 

 

 

B. X­ray and laboratory results (State if non or pending.)

 

 

 

 

 

 

20.

DIAGNOSIS (if occupational illness specify etiologic agent and duration of exposure.) Chemical or toxic compounds involved?

D Yes

D No

 

 

 

 

 

ICD­9 Code ___

___ ___ ­ ___ ___

 

 

 

 

21.

Are your findings and diagnosis consistent with patient's account of injury or onset of illness? D Yes

D No If "no", please explain.

 

 

 

 

 

 

22.

Is there any other current condition that will impede or delay patient's recovery? D Yes

D No If "yes", please explain.

 

 

 

 

 

 

 

 

 

23.

TREATMENT RENDERED (Use reverse side if more space is required.)

 

 

 

 

 

 

 

 

 

 

 

 

24.

If further treatment required, specify treatment plan/estimated duration.

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

If hospitalized as inpatient, give hospital name and location

 

Date

Mo.

Day Yr.

Estimated stay

 

 

 

admitted

 

 

 

 

 

 

 

 

 

 

 

 

26.

WORK STATUS ­­ Is patient able to perform usual work?

D Yes D No

 

 

 

 

 

 

If "no", date when patient can return to: Regular work

____/____/____

 

 

 

 

 

 

Modified work

____/____/____

Specify restrictions ______________________________________________

 

 

 

Doctor's Signature ______________________________________________________

 

CA License Number ________________________________

Doctor Name and Degree (please type) ______________________________________

 

 

IRS Number ________________________________

Address _______________________________________________________________

Telephone Number (_____)__________________________

 

 

 

 

 

 

 

 

FORM 5021 (Rev. 4) 1992

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation

for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.

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