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Download Our CA Injured Worker Intake Form [New and Updated]

Easy workers’ comp billing starts with a thorough intake process.

California’s Division of Workers’ Compensation (DWC) has strict billing and payment guidelines. For providers, staying in compliance (and ensuring proper reimbursement) means getting all the necessary information from the beginning. For that, your office needs a comprehensive injured worker intake form.

As it happens, we created an intake form that any California workers’ comp provider can use to get exactly what they need, from the start.

In California, the magic word for compliant workers’ comp billing is complete. Any missing or incorrect information becomes a liability, something the claims administrator can use to deny payment.

We designed this intake form with one purpose in mind: to help providers generate compliant Original Bills the first time, every time. The fields we included are aligned with the DWC Medical Billing and Payment Guide, so your office has exactly what it needs to correctly complete required forms like the CMS 1500.

The form includes fields for all DWC-required information, along with important optional information that can reduce friction later in the billing process, including contact information for adjusters, managers, and attorneys. The form also features clearinghouse information, so you can see at a glance which clearinghouse is responsible for processing the bill on behalf of the claims administrator.

Download the form here; it’s our gift to you. We hope this form will make the process of workers’ comp billing a little easier for any provider who needs a little help navigating this complex, occasionally infuriating system.


The new standard intake form is just one of the ways DaisyBill helps providers ensure fast, compliant billing that results in proper reimbursement. With our complete billing software, official forms like the CMS 1500 can be auto populated with information gathered during intake. That means less time, money, and resources spent on billing.
See for yourself. Schedule a free demonstration today.

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