DaisyBill recommends that healthcare providers use this or a similar form for all workers’ comp patients so that all necessary patient demographics and claim information is obtained for billing purposes.

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.

This sample patient intake form contains the following recommended fields: 

Patient Information

Required:

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

Optional:

1. Phone Number

Injury Information

Required:

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

• Electronic Billing:

            • Payer ID  

            • Clearinghouse

• Paper Billing

            • Mailing Address

Optional:

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 a fillable template of daisyBill’s tried and true intake sheets, click a link below!

Downloadable and Fillable Patient Intake Forms:

California (With Billing Info)

California (Without Billing Info)

New York

Stay tuned for fillable intake sheets for additional states, coming soon!

DaisyBill Resources

California Workers' Compensation: Master the Original Bill Webinar

Requests for Authorization in California Workers’ Compensation Webinar

REQUEST DEMO