Workers Compensation Intake Form PDF Details

If you're injured on the job, it's important to report the injury as soon as possible. You can do this by filling out a workers compensation intake form. This form will help your employer and the workers compensation insurance company track your claim and provide you with the necessary benefits. There are a few things you should keep in mind when filling out a workers compensation intake form. First, be sure to include all of your contact information so that they can reach you if they have any questions. Also, make sure to describe how the injury occurred and list any treatments or medications you've received for the injury. Finally, sign and date the form so that it's official.

Below are some specifics about workers compensation intake form. You may learn its length, the actual time necessary to fill out the form, the blanks you'll have to fill in, and so on.

QuestionAnswer
Form NameWorkers Compensation Intake Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesworkers comp designated provider letter, worker comp intake form template, workers comp intake, workers compensation patient intake form

Form Preview Example

WORKERS’ COMPENSATION CASE INTAKE FORM

Date

 

 

 

 

 

 

 

 

 

 

CLIENT INFORMATION

Client

 

 

 

 

Address

 

Phone (H)

 

(W)

Cell

 

 

 

 

 

Date Retainer Agreement Signed

 

SSN

 

 

 

 

E-Mail

 

Date of Birth

 

 

 

 

Driver’s License

 

Education

 

 

 

 

 

 

 

 

 

 

 

Spouse/Partner’s Name

 

 

 

 

Spouse/Partner Phone

 

Dependents

 

 

 

 

Referred By

 

Emergency Contacts (Name/Address/Phone)

 

 

 

 

 

 

 

 

EMPLOYMENT/INSURANCE/UNION MEMBERSHIP

Primary Employer

 

 

 

 

Address

 

 

Wage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurer

 

 

 

 

Adjuster

 

 

 

Address

 

 

 

 

Claim No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

Managed Care Organization

Yes

No

Policy No.

 

 

When was the comp insurer notified of the claim being filed?

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Hire

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently Working

 

 

 

 

Scheduled Days Off

 

Wage Loss Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary Employer

 

 

 

 

Address

 

 

Wage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurer

 

 

 

 

Adjuster

 

 

 

Address

 

 

 

 

Claim No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

Managed Care Organization

Yes

No

Policy No.

 

 

When was the comp insurer notified of the claim being filed?

Date

 

 

 

Has documentation of the wage at the secondary job been obtained?

 

Yes No

Date of Hire

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

Currently Working

 

 

 

 

Scheduled Days Off

 

Wage Loss Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

Non-Industrial Carrier

Yes

No

Policy No.

Carrier

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Private Health Carrier (if any)

Yes

No

Policy No.

Carrier

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Union Membership

Yes

No

Local No.

Union Name

 

 

 

 

 

 

 

 

 

 

 

 

 

INJURY

Date of Injury

 

 

Claim No.

WCB No.

 

 

 

 

WCD No.

 

 

 

 

 

 

 

 

 

Body Part(s) Injured

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How Did the Injury Occur

Where Did the Injury Occur (City/State)

 

 

PRIOR CLAIMS

Date of Prior Workers’ Comp Claim

 

 

Amount of Award $

 

Date of Prior Workers’ Comp Claim

 

 

Amount of Award $

 

Date Worker’s Statement or Deposition Taken

 

 

 

 

 

 

 

 

 

 

 

 

 

PREVIOUS MOTOR VEHICLE ACCIDENTS AND OTHER PRIOR INJURIES

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

MEDICAL CONDITIONS PRE-EXISTING THIS INJURY

PRIOR ARRESTS AND CONVICTIONS

MENTAL HEALTH, ALCOHOL, DRUG USE (CURRENT AND HISTORY)

 

 

 

 

 

 

 

 

 

DEADLINES TO CALENDAR

 

Date of Notice of Closure

 

 

 

Statute Runs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

60 days from date of Order

 

Date of Reconsideration Order*

 

 

Statute Runs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30 days from date of Reconsideration Order

 

Date of Denial*

 

 

Statute Runs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

60 days from date of mailing of denial

 

Aggravation Claim

 

 

 

Statute Runs

 

 

 

 

 

 

 

 

 

 

 

 

 

5 years from date of first Notice of Closure, if disabling;

 

 

 

 

 

 

 

 

 

 

 

5 years from date of Notice of Acceptance, if nondisabling

 

* Request hearing immediately

 

 

 

 

 

 

Date of Opinion and Order

 

 

 

Statute Runs

 

 

 

 

 

 

 

 

 

 

 

 

 

30 days from date of Opinion and Order

 

Date of Board Order Mailing

 

 

 

Statute Runs

 

 

 

 

 

 

 

 

 

 

 

 

 

30 days from date of Order on Review

 

Date Appellate Brief Due

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

Date of scope of acceptance demand letter

 

Statute Runs

 

 

Date of Director’s Admin. Review Order

 

 

 

60 days from date of demand

 

Statute Runs

 

 

 

 

 

 

 

60 days from Dir. Admin. Review Order

Date of Medical Services Order

 

 

Statute (OAR) Runs

 

 

Vocational Services Issue

 

Statute Runs

 

 

 

 

 

 

 

 

 

WCD

Date Request for Hearing Filed Hearing Date

Date Client Notified

WCB

Date Request for Hearing Filed Hearing Date

Date Client Notified

LIEN ITEMS

□

□

□

Child Support Liens

Medicaid

Welfare Assistance

□

□

□

Unemployment Benefits

Medicare

Private Health Carrier

□

□

□

Social Security Disability

Oregon Health Plan

Other

NAMES OF PHYSICIANS, MEDICAL FACILITIES WHERE TREATED

 

Physician or Facility

 

Address

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTS FOR RECORDS

Records from treating physician

Date Requested

 

Rec’d

 

 

Hospital records

Date Requested

 

Rec’d

 

 

Other physician records

Date Requested

 

Rec’d

 

 

Other physician records

Date Requested

 

Rec’d

 

 

Document demand to employer

Date Requested

 

Rec’d

 

 

Medical releases obtained

Date Requested

 

Rec’d

 

 

 

 

 

 

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

THIRD PARTY RESPONSIBILITY

Third Party Potential

Potentially Responsible Party

Theory of Liability

SOL

Notes

WITNESSES

 

 

 

 

Interviewed

Subpoenaed

Name

 

Address

 

 

 

 

 

 

 

Telephone

 

 

 

Name

 

Address

 

 

 

 

 

 

Telephone

 

 

 

Name

 

Address

 

 

 

 

 

 

Telephone

 

 

 

Name

 

Address

 

 

 

 

 

 

Telephone

 

 

 

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

How to Edit Workers Compensation Intake Form Online for Free

It is really straightforward to complete the workers comp designated provider letter spaces. Our tool will make it virtually effortless to work with any specific PDF file. Down the page are the primary four steps you need to take:

Step 1: The initial step requires you to choose the orange "Get Form Now" button.

Step 2: As soon as you've accessed the editing page workers comp designated provider letter, you will be able to discover each of the options readily available for the document at the upper menu.

These sections will make up the PDF document that you will be filling out:

stage 1 to filling in workers compensation client intake form

Complete the EMPLOYMENTINSURANCEUNION MEMBERSHIP, Primary Employer, Wage, Insurer, Address, Managed Care Organization When was, Yes No, Date of Hire Currently Working, Wage Loss Paid, Secondary Employer, Wage Insurer, Address, Managed Care Organization, Yes No, and Address fields with any information that are requested by the system.

workers compensation client intake form EMPLOYMENTINSURANCEUNION MEMBERSHIP, Primary Employer, Wage, Insurer, Address, Managed Care Organization When was, Yes No, Date of Hire Currently Working, Wage Loss Paid, Secondary Employer, Wage Insurer, Address, Managed Care Organization, Yes No, and Address fields to fill out

The system will ask you for details to conveniently submit the area NonIndustrial Carrier, Yes No, Policy No, Carrier Address, Private Health Carrier if any, Yes No, Policy No, Carrier, Address, Union Membership Union Name, Date of Injury WCB No, Body Parts Injured, How Did the Injury Occur, Yes No, and Local No.

stage 3 to filling out workers compensation client intake form

The Where Did the Injury Occur, PRIOR CLAIMS, Date of Prior Workers Comp Claim, Amount of Award, Amount of Award, and PREVIOUS MOTOR VEHICLE ACCIDENTS section could be used to indicate the rights and responsibilities of both parties.

Where Did the Injury Occur, PRIOR CLAIMS, Date of Prior Workers Comp Claim, Amount of Award, Amount of Award, and PREVIOUS MOTOR VEHICLE ACCIDENTS in workers compensation client intake form

Check the sections MEDICAL CONDITIONS PREEXISTING, PRIOR ARRESTS AND CONVICTIONS, and MENTAL HEALTH ALCOHOL DRUG USE and next complete them.

step 5 to finishing workers compensation client intake form

Step 3: If you're done, click the "Done" button to export your PDF document.

Step 4: In order to prevent possible forthcoming complications, take the time to have up to several copies of any form.

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