Work Comp
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Create Claim
  A. Patient's Information
1. Name:
A value is required.
A value is required.
  2. Soc. Sec. #:
A value is required.
 
Last
First
MI
      
3. Mailing address:
 
Number and Street
City
State
   Zip Code
4. Home phone #:
5. Date of Birth:
   6. Date of injury/onset of illness:
7. WCB Case # (if known):
8. Carrier Case #:
   9. Patient's Account #:
       
B. Doctor's Information      
1. Your name:
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A value is required.
A value is required.
  2. WCB Authorization #::
A value is required.
 
Last
First
MI
      
3. WCB Rating Code:
4. Federal Tax ID #:
   The Tax ID # is the (check one):
SSN
EIN
5. Office address:
 
Number and Street
City
State
   Zip Code
6. Billing group or practice name:
7. Billing address:
 
Number and Street
City
State
   Zip Code
8. Office phone #:
9. Billing phone #:
   10. Provider's NPI  #:
11. Referring Doctor:
A value is required.
A value is required.
A value is required.
 
 
Last
First
MI
      
       
C. Billing Information
       
1. Employer's insurance carrier:   2. Carrier Code #: W
3. Insurance carrier's address:
 
Number and Street
City
State
   Zip Code
4. Diagnosis or nature of disease or injury:
Enter ICD9 Code: ICD9 Descriptor:		      
(1)      
(2)      
(3)      
  Relate ICD9 codes in (1), (2) or (3) to Diagnosis Code column by line
     
       
Check here if services were provided by a WCB preferred provider organization (PPO).
 
Total Charge Amount Paid
(Carrier Use Only)		 Balance Due
(Carrier Use Only)

$

$

$
 
Dates of Service
    

Use WCB Codes

          
From
MM
DD
 YY To
MM		 DD YY Place
of
Service		 Leave
Blank

Procedures, Services or Supplies

 Diagnosis Code $ Charges Days/
Units		 COB Zip code where service was
rendered

CPT/

HCPCS

 MODIFIER          
 
                         
 
                         
 
                         
 
                         
                             
Board Authorized Health Care Provider - Check one:      
I provided the services listed above. I actively supervised the health-care provider named below who provided these services.
Provider's name  
Specialty
Board Authorized Health Care Provider signature:      
Name Signature Specialty Date
       
Claim Created Successfully