Sample Patient Intake Form for Workers’ Compensation

Patient intake forms for workers’ compensation require more and different information than those for group health. The heavily regulated nature of workers’ comp, particularly in California, means that meticulous record-keeping is essential for successful medical billing.

Sample Patient Intake Form for Workers’ Compensation

This sample patient intake form contains the following recommended fields: 

Patient Information


  1. Name
  2. SSN
  3. DOB
  4. Gender
  5. Address


  1. Phone Number

Injury Information


  1. Employer Name
  2. Injury Start Date
  3. Claims Administrator Name (Carrier)
  4. WC Claim Number
  5. Billing Address
  • Electronic Billing:

            Payer ID  


  • Paper Billing

            • Mailing Address


  1. Injured Body Part & Description
  2. Employer/Insurer MPN Name
  3. PTP Name
  4. PTP Phone Number
  5. Claim Status
  6. ADJ Number
  7. RFA Fax

Optional Contact Information 

  1. Adjuster Name/Phone/Fax
  2. Nurse Case Manager Name/Phone/Fax
  3. Applicant Attorney Name/Phone/Fax
  4. Defense Attorney Name/Phone/Fax
Note: One frequently-overlooked component of intake forms is information on the Request for Authorization (RFA); we cannot emphasize enough how important RFAs are for payment. Watch a free recording of our RFA webinar for more information.


To download the form, click this link.

DaisyBill Resources

Webinar: Overview of California Workers’ Compensation

Webinar: Requests for Authorization for California Workers’ Compensation


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