Workers' Compensation Patient Form - English

All fields with an asterisk (*) are required.

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2020-CORP-HCA Healthcare-Workers Comp English-PHI

Name*

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

What hospital did you go for treatment?

Date of injury or accident

Employment Information: What is the name and address of the employer you were working for when the accident happened?

Employer Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Who should we contact at your place of business?

Name

First Name

Last Name

Contact Phone

Do you know the name and address of the worker's compensation insurance carrier?

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

If you know it, please provide a claim number

If you know it, please provide the name of your claims adjuster

Health Insurance

Name of Health Insurance Company

Name of individual whose whole name is on the policy

Identification Number

Group Number

Attorney Information

Have you hired an attorney to help you in this matter?

Yes No

If yes, please give name, address and phone:

Attorney Name

First Name

Last Name

Attorney Address

Address Line 1

Address Line 2

City

State

ZIP Code

Attorney Phone