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Workers' Compensation Patient Form
Employer Information
Company Name
*
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Information
Workers' Compensation Insurance Name
*
Patient Information
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 a claim number been generated?
*
Yes
No
Claim Number
*
SSN
*
Date of Injury
*
-
Month
-
Day
Year
Date
Description of Injury
*
Which clinic is the visit scheduled at?
*
Please Select
Gretna
Harvey
Mid-City
Uptown
LaPlace
Workers’ Compensation Acknowledgment and Financial Responsibility Agreement
*
By signing below, I acknowledge that I have read and fully understand The Urgent Care's Patient Responsibility and Financial Policy, revised July 2016, and I accept and agree to all of its terms and conditions. I understand that I am financially responsible for any charges not covered by workers’ compensation and/or my employer. If, after three months, I fail to provide a claim number or if my employer has not fulfilled payment, I accept responsibility for the remaining balance of today’s visit. I give consent for any medical records and billing information related to this date of injury to be released to the Workers' Compensation Insurance and Employer listed above. I confirm that I have informed my employer of the work-related injury for which I am seeking treatment today at The Urgent Care, and I understand it is my responsibility to notify my employer and ensure the injury is reported to their workers’ compensation insurance carrier. I further acknowledge that failure to do so may result in delays or denial of payment, and that I may be held financially responsible for the cost of today’s visit if the claim is not accepted or paid.
Date of Authorization
*
-
Month
-
Day
Year
Date
I understand that a physician may not be available for treatment and that I may be evaluated by a mid-level provider (Nurse Practitioner or Physician Assistant). If my workers’ compensation claim is denied for this reason, I acknowledge that I and/or my employer will be fully responsible for the remaining balance of today’s visit.
*
Yes
No
Submit
Submit
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