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Submit a Worker's Compensation Claim

If you were injured while on the job, your treatment may be covered under the Workers' Compensation provisions in insurance law. We can help you by submitting your Workers' Compensation claim on your behalf. Before we can submit a claim, you must report the injury to your employer. Your employer will give you a claim number. You must give this claim number to your health care providers in order for your treatment to be paid. If you have questions about your Workers' Compensation benefits, please contact your employer.

Please provide the following information so that we can submit your Workers' Compensation claim:

 

Patient Information *Indicates a required field
Patient Name: * Hospital Account No.: *
Facility Name *
Insurance Information
Insurance Coverage:
Carrier Name: * Employer Name: *
Street: * Employer Phone: *
City: * Claim No.: *
State: * Date of Accident: *
Zip Code: *  
Phone: *  
Contact Information
Email Address *
  I certify that I am the owner of the email account and I am the patient, the financially responsible party for the patient's account, or I am authorized to act on behalf of the patient.
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