Workers Compensation Form - Dupage Medical Group
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1Workers’ Compensation Form
If your illness or injury is related to your work, your company carries insurance to pay your medical bills. Please complete this form
so that your claim is filed with your company properly. If you agree to a settlement under the workers compensation act, be sure
that all your medical bills have been included in the settlement. If your claims are denied under the worker’s compensation act,
you will become fully responsible for payment. You should then contact our Customer Service Department at 630-942-7998 to
make payment arrangements.
PATIENT INFORMATION
P
: _________________________________________________________________________________________
ATIENT
Last Name
First Name
MI
D
B
: ___________________
S
S
#:_______-______-_________
ATE OF
IRTH
OCIAL
ECURITY
EMPLOYMENT INFORMATION
________________
E
: ______________________________________________________ P
: (______)
MPLOYER AT TIME OF INJURY
HONE
E
’
A
: __________________________________________________________________________________________
MPLOYER
S
DDRESS
Street Address
City
State
Zip Code
R
?
YES
NO
R
T
:___________________________________________________________
EPORT OF INJURY COMPLETED
EPORTED
O
Name / Title
P
: (______)_____________________ F
: (______)_____________________
HONE
AX
INJURY DETAILS
D
: ________________ T
(
(
)
):________________________________________________
ATE OF INJURY
YPE OF INJURY
BODY PART
S
INVOLVED
H
? (
,
,
.): ______________________________________________________________________
OW DID INJURY HAPPEN
FALLING
TRIPPING
ETC
A
?
YES
NO
NY PRIOR TREATMENT BY OTHER PROVIDERS
I
YES,
?
E
R
O
H
C
MD
P
C
P
O
F
WHAT TYPE OF PROVIDER
MERGENCY
OOM
CCUPATIONAL
EALTH
OMPANY
RIMARY
ARE
ROVIDER
THER
___________________
P
H
N
: _________________________________________________ P
#: (______)
ROVIDER OR
OSPITAL
AME
HONE
CLAIM INFORMATION
If the following information is unknown at the time of the appointment, please contact your employer for the required information
and contact our Customer Service Department within 5 business days. Failure to provide this information may result in any balance
from your visit becoming your responsibility.
R
I
C
: _________________________________________________________________________________
ESPONSIBLE
NSURANCE
OMPANY
C
A
: ______________________________________________________________________________________________
LAIMS
DDRESS
Street Address
City
State
Zip Code
C
N
: ____________________________ C
A
:______________________________________________________
LAIM
UMBER
LAIM
DJUSTER
P
#: (______)-_________________ __ F
# : (______)-___________________ N
C
M
A
?
YES
NO
HONE
AX
URSE
ASE
ANAGER
SSIGNED
________________
__________________
I
YES, NCM N
: _____________________________ P
: (______)
F
: (______)
F
AME
HONE
AX
___________________
A
?
YES
NO
A
N
:_______________________ A
P
#:(______)
TTORNEY ON FILE
TTORNEY
AME
TTORNEY
HONE
_________________
___________________
A
F
#:(______)
’
# (if claim filed)
TTORNEY
AX
ILLINOIS WORKERS
COMPENSATION CLAIM
I hereby authorize DuPage Medical Group to release to my employer, workers’ compensation representative, or their
designees, any information which may be requested concerning my condition or treatment.
Signature: ______________________________________________________________ Date: _________________
DMG Staff Instructions: Email completed form to Registration (rq-regqueue) and send the original form to the Workers
Compensation Team at Highland Oaks via interoffice mail.
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