Workers’ Compensation Claim Request

Patient Information

First Name

Last Name

Date of Birth

Address

Phone

Date of Injury

Injured Body Part(s)

*** If multiple body parts, list all and include side (left or right)

Employer Information

Name

Address

Phone

Case Manager Name

Case Manager Phone

Case Manager Fax

Insurance Information

Insurance Carrier

Claim Number

Billing Address

Adjuster Name

Adjuster Phone

Adjuster Fax

Insurance Company

Member ID

Group ID

Claims Address

Back of Insurance Card

Policyholder Name

Policyholder/Subscriber - the person whose employer provides the policy as a benefit or person paying for the insurance premium

Patient's relationship to subscriber

Child

Self

Spouse

Other