First Responder Intake – Helping injured workers recover

First Name

Last Name

Middle Initial Name

Gender

Address

Primary Phone

Alt Phone

Date of Birth

Date of Injury

Claim

Description of Injury

Worker Comp Insurance

Name

Phone

Address

Adjuster

Name

Phone

Fax

Workers Comp Doctor

Name

Phone

Address

Workers Comp Medications

Employer

Name

Phone

Address

Attorney

Name

Phone

I acknowledge and agree to the HIPAA Privacy Notice

By submitting this form, I authorize Injury Care Pharmacy to use and disclose my health information as needed to verify my prescription, coordinate care, process billing, and ship medications, in accordance with HIPAA and applicable law. I understand I may request a copy of the Privacy Notice at any time.

Start Your Injury Care Pharmacy Enrollment

Complete this secure form and our team will verify your Workers’ Comp or Heart & Lung claim,
contact your doctor/adjuster, and coordinate delivery. Most patients finish in 2–3 minutes.

Whatever you’re going through, we’re here to support you with personalized care and the services you need to feel better, faster.

Worker Comp Insurance

Adjuster

Workers Comp Doctor

Employer

Attorney

Start Your Injury Care Pharmacy Enrollment

Services

Quick Links

Contact Us

info@injurycarepharmacy.com

1-800-576-0137

1-888-351-9542

6918 Stirling Rd. Hollywood Florida 33024

ePrescribe NCPDP ID: 5742223