Louisiana > Workers Comp
Disputed Claim For Medical Treatment WC-1009 - Louisiana
| Disputed Claim For Medical Treatment Form. This is a Louisiana form and can be used in Workers Comp . |
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Mail to: OWCA Medical Services ATTN: Medical Director P.O. Box 94040 Baton Rouge, LA 70804 1. Social Security No. ______ - _____ -_______ 2. Date of Injury/Illness _____-_____-________ 3. Parts of Body Injured ___________________ _____________________________________ 4. Date of Birth _______-______- _______ 5. Date of This Request _____-_____-________ 6. Claim Number ________________________ DISPUTED CLAIM FOR MEDICAL TREATMENT NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS THE INSURER HAS ISSUED A DENIAL FOR THE MEDICAL SERVICES IN DISPUTE AS PER R.S. 23:1203.1 J. GENERAL INFORMATION Claimant files this dispute with the Office of Workers' Compensation Medical Services Director. This office must be notified immediately in writing of changes in address. An employee may be represented by an attorney, but it is not required. 7. This request is submitted by ____ Employee _____ Employer ____Insurer ____Health Care Provider _____Other __________________ A. Copies of all relevant medical records must be included with this request. B. A copy of the denial letter issued by the insurance carrier must be attached to this request. EMPLOYEE 8. Name __________________________________ Street or Box _____________________________ City ____________________________________ State ____________________ Zip ___________ Phone ( _____ ) __________________________ EMPLOYEE'S ATTORNEY 9. Name _______________________________ Street or Box _________________________ City ________________________________ State ________________________________ Phone ( _____ ) _______________________ Fax ( _____ ) _______________________ INSURER/ADMINISTRATOR (circle one) 11. Name _______________________________ Street or Box _________________________ City ________________________________ State ________________________________ Phone ( _____ ) _______________________ Fax ( _____ ) _______________________ EMPLOYER 10. Name __________________________________ Street or Box ____________________________ City _ _________________________________ State ___________________ Zip ___________ Phone ( _____ ) _________________________ Fax ( _____ ) _________________________ EMPLOYER/INSURER'S ATTORNEY TREATING/REQUESTING PHYSICIAN 12. Name _________________________________ Street or Box ____________________________ City _ _________________________________ State ___________________ Zip ____________ Phone ( _____ ) __________________________ Fax ( _____ ) __________________________ 13. Name _______________________________ Street or Box _________________________ City ________________________________ State ________________________________ Phone ( _____ ) _______________________ Fax ( _____ ) _______________________ LWC-WC 1009 11/2010 1 American LegalNet, Inc. www.FormsWorkFlow.com 15. PLEASE PROVIDE A SUMMARY OF THE DETAILS REGARDING THE ISSUE AT DISPUTE: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ You may attach a letter or petition with additional information with this disputed claim. The information given above is true and correct to the best of my knowledge and belief. _____________________________________________ SIGNATURE OF REQUESTING PARTY _______________________ DATE LWC-WC 1009 11/2010 2 American LegalNet, Inc. www.FormsWorkFlow.com
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