Submit workers' compensation information

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 healthcare 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:

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Patient information

Patient name

Hospital account no.

Facility name

Insurance information

Carrier name

Street

City

State

ZIP code

Phone

Claim number

Date of accident

Employer information

Employer name

Employer phone

Contact information

Your email address

Yes, I certify that I am the owner of the email account and am the patient, the legally responsible party for the patient's account, or I am authorized to act on behalf of the patient.