Workers' Compensation Intake Form

The Workers' Compensation Intake Form collects all the information needed to evaluate and document a workplace injury or occupational illness. It captures the specifics of the incident including date, time, location, and mechanism of injury, along with the employer's information and workers' compensation insurance details. This thorough documentation is essential for claim processing and ensures your practice can provide appropriate care from the first visit.

The form includes detailed body diagram references for injury location, fields for describing how the injury occurred, and questions about prior injuries to the same body part. It also captures the employer's contact information, the workers' compensation carrier and claim number, and whether the injury has been reported to the employer. Return-to-work status and work restriction documentation fields help your providers communicate clearly with employers and adjusters.

Designed for occupational medicine clinics, urgent care centers, orthopedic practices, and any provider that treats work-related injuries. This form meets the documentation requirements of most state workers' compensation boards and helps practices manage the unique billing and reporting requirements associated with occupational injury cases.