Providers who treat injured workers can’t afford to let administrative oversights derail payment, especially in California. Any error or missing information can give a payer the opportunity to delay or deny reimbursement.

Your first line of defense: an airtight injured worker intake process.

In the last year, daisyBill has processed over 2.5 million bills for our clients. Using information from payment denials, we updated our California Injured Worker Intake Form (below), a free resource for all providers.

This fillable PDF captures the information your practice needs to ensure clean, compliant bills that give the payer no (or at least fewer) reasons to do anything other than pay on time and in full.

Download your copy here!

2026 CA Injured Worker Intake Form

We designed this intake form to help providers generate compliant original bills the first time, every time. The fields we included align with the California Division of Workers’ Compensation (CA DWC) Medical Billing and Payment Guide, so your office has everything it needs to complete required forms, such as the CMS-1500, correctly.

The form includes fields for all state-required information, along with important optional information that can reduce friction later in the billing process. Sections include:

• Injured Worker Demographics, featuring all required information, plus an optional field for contact information.
• Claims Administrator Information, featuring optional fields for adjustor contact information.
• Injury Claim Information, including fields for the injury’s status (e.g., accepted, disputed, denied).

Critical: Authorization Information

All too often, payers deny providers reimbursement by claiming that the treatment was never authorized. For that reason, in addition to the fields above, our intake form includes the following:

• RFA Fax Number: Identify exactly where to send Requests for Authorization, which providers must submit for every treatment.
• Employer MPN: Avoid denials based on non-participation in the employer or insurer’s Medical Provider Network by establishing the applicable network early on.

Finally, the second page of the intake form (below) establishes the provider’s status as the Primary Treating Physician or as an authorized referral provider.

Gathering these details early is a worthwhile investment of time and effort, as protection against needless delays and denials of your reimbursement.

Consider this form our gift to your practice, and feel free to share it with other California providers who accept workers’ comp patients. Download it here (no email address required).

daisyBill gets providers paid faster and more accurately for workers’ comp treatment. Click to see how:

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