Work-related Injury Assistance Form

 

ElevatePFS can help ensure accurate and timely payment for your work-related injury care. We partner with health systems to investigate the details of your accident or injury, so that workers' compensation insurance pays all or part of your hospital bill. If you were treated for injuries arising out of a work-related accident, please fill out the form below with the information you have available (all fields are not required) and a representative from our WC team will contact you if needed. 

WC Form
Patient Name
Patient Name
Adjuster's Name
Adjuster's Name
First
Last
Attorney Name (if applicable)
Attorney Name (if applicable)
First
Last