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Workers' Compensation Employer Form
Patient
Patient Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Has the patient reported the injuries to their employer?
*
Yes
No
Work-Related injuries must be reported PRIOR to visit.
Once the work-related injury has been reported to the employer, a claim should be initiated. A claim number will be required in order to move forward with all work-related injury visits. Once a claim has been initiated, please re-start this form.
Has the claim been reported to Workers' Comp?
*
Yes
No
Schedule a Private Pay Visit.
If the employer chooses to pay for visit with a company credit card, please call our clinic at 504-635-2273 to schedule a private pay visit at any of our locations.
Has a claim number been generated?
*
Yes
No
Claim Number
*
SSN
*
Patient Phone Number
*
Please enter a valid phone number.
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Email
example@example.com
Date of Injury
*
-
Month
-
Day
Year
Date
Description of Injury
*
Location of Injury
*
Has the visit already been scheduled at one of our five clinics?
*
Yes
No
Schedule Worker-Related Injury Online!
Schedule the visit online at any of our five clinics located through out the Westbank, New Orleans, and River Parishes. myurgentcare.me/checkin
Which clinic is the visit scheduled at?
*
Please Select
Gretna
Harvey
Mid-City
Uptown
LaPlace
What day & time is the visit scheduled for?
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Billing Information
Workers' Compensation Insurance Name
*
Workers' Compensation Insurance Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Workers' Compensation Insurance Phone Number
*
Please enter a valid phone number.
Employer Information
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Contact Name
*
Employer Contact Phone Number
*
Please enter a valid phone number.
Employer Contact Email
*
example@example.com
Employer Authorization for Treatment
*
Date of Authorization
*
-
Month
-
Day
Year
Date
I understand that if the claim gets denied due to the patient being examined by a mid-level provider as a physician may not be available for treatment, the patient and/or employer will be fully responsible for the remaining balance.
*
Yes
No
Submit
Submit
Should be Empty: