Downloadable NY Injured Worker Intake Form

One of the best ways to make workers’ comp billing a little easier? Start with a bulletproof intake process.

As New York State transitions to faster, more efficient electronic billing for workers’ comp, it’s crucial for providers to prepare. Protecting your revenue as bills and payments wind their way through the labyrinth of new rules and new systems means prioritizing thorough documentation from the first patient interaction.

To wit: we created a NY-specific patient intake form that allows your office to gather all the required (and optional) information you need. Download our form, and make the rest of the billing process smoother.

The Changing Tide of NYS Workers’ Comp

Currently, NY providers have the option of billing for workers’ comp using the universal CMS-1500 medical billing form, in lieu of the NY-specific C-4, C-4.2, OT/PT-4, PS-4, and C-AMR billing forms. NY providers currently also have the option to utilize electronic billing. If a NY provider chooses to bill electronically, claims administrators are required to return an electronic Explanation of Benefits (EOB).

Soon enough, however, electronic billing will be mandatory state-wide (although there will be a “hardship exception,” the details of which are yet unknown).

Eventually, all New York providers will be required to electronically submit workers comp bills to claims administrators with the change expected on or about January 1, 2020. The CMS-1500 form, along with forms C-4, C-4.2, OT/PT-4, PS-4, and C-AMR will be a thing of the inefficient, environmentally-unfriendly past.

If your office hasn’t already, it’s time to start the transition. Butterfly-like, you’ll emerge into 2020 ready to bill quickly, compliantly, and with less friction — provided your office gathers the right information.

Patient Intake Form

New York’s Workers’ Compensation Board (WCB) has strict billing and payment guidelines. For providers, staying in compliance (and ensuring proper reimbursement) means getting all the necessary data from the beginning. For that, your office needs a comprehensive injured worker intake form, like the one below:

In workers’ comp billing, any missing or incorrect information becomes a liability — something the claims administrator can use to deny payment.

We designed this intake form to help NY providers generate compliant Original Bills the first time, reducing complications later on. The fields we included are aligned with WCB requirements. This way, your office has exactly what it needs to bill correctly whether you’re using NY-specific billing forms, the paper CMS-1500, or electronic billing.

The form includes fields for all WCB-required information, along with important optional information that can reduce friction later in the billing process, such as the attending doctor’s information. The form also features information on the electronic billing clearinghouse, 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, and consider it our gift to your office. We hope this form will make the process of workers’ comp billing that much easier for any provider who needs a little help navigating this complex system.

For additional information on filing a CMS-1500 in NY state, including required supporting documentation and filing requirements please refer to DaisyBill’s New York Bill Instructions: CMS-1500.


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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