Downloadable NY Injured Worker Intake Form

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Downloadable NY Injured Worker Intake Form

One of the simplest ways to make workers’ comp billing easier: start with a solid intake process.

As New York State moves to mandatory electronic billing for workers’ comp, it’s crucial for providers to prepare.

While e-billing will make it easier to get reimbursed quickly and accurately, gathering the right details at intake will make the process even smoother.

To help providers, we created a New York-specific intake form with all the required (and optional) details. Download the form below, and enjoy better billing!

Note: this article was updated on November 19, 2024 to reflect the most current information.

NY Workers’ Comp e-Billing: Mandatory in 2025

Currently, New York providers have the option of e-billing. But starting August 1, 2025, claims administrators will not have to pay non-electronic bills.

In other words, e-billing will be required.

If your practice hasn’t already, it’s time to start the transition. Choose your approved XML Submission Partner now (yes, daisyBill is one of those), and hit the proverbial ground running.

You’ll be ready to bill quickly, compliantly, and with less friction—provided your office gathers the right intake information, of course.

New York Injured Worker Intake Form

The New York 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, which you can download here:

In workers’ comp billing, any missing or incorrect information becomes a liability—i.e., something the claims administrator can use to deny payment. We designed this form to help New York 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.

The form includes fields for all WCB-required information, along with important optional information that can reduce friction later in the billing process (e.g., attending doctor’s information). The form also features information on the clearinghouse used by the payer, so you can see at a glance which entity is responsible for accepting and responding to your e-bills.

Download the form, and consider it our gift to you. We hope this form will make workers’ comp billing that much easier for any provider who needs a little help navigating this complex system.

NY Workers’ Comp: More Helpful Links

To learn more about treating injured workers in New York, see our other helpful articles:

New York How-To: Register for XML Submissions

New York: 3 Key Narrative Report Requirements

NY e-Billing Guide: CMS-1500 & XML Submissions

New York: WCB Update Affirms Electronic EOR Requirement

New York: Exceptions to Reporting Requirements

NY WCB Bulletin: Telehealth Bill Objections

NY Provider Reminder: Mandatory e-Billing Approaches!

If you have any questions about e-billing for New York workers’ comp, contact our experts using the pink chat icon at the bottom right of this page, or email us at info@daisybill.com.


Nationwide, daisyBill increases revenue and decreases hassle for providers who treat injured workers. Schedule a free demonstration below.

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