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Notice Of Payment Modification Suspension Termination Or Controversion Of Compensation Of Medical Benefits WC-1002 - Louisiana

Notice Of Payment Modification Suspension Termination Or Controversion Of Compensation Of Medical Benefits Form. This is a Louisiana form and can be used in Workers Comp .
 Fillable pdf Last Modified 11/17/2013
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EMPLOYER/PAYOR MAIL TO: OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 1. Employee Social Security No. ______ -_____-_______ 2. Payor Claim No.:______________________________ 3. Date of Injury/Illness ___________________________ 4. Date of Notice: ________________________________ NOTICE OF PAYMENT, MODIFICATION, SUSPENSION, TERMINATION OR CONTROVERSION OF COMPENSATION OR MEDICAL BENEFITS 5. Purpose of Form (check one): Initial Payment ____ 6. (a) Modification ____ Suspension ____ Termination____ Controversion ____ Employee Name: Address: Telephone: ______________________________________________ ______________________________________________ ______________________________________________ (b) Employee Representative Name (if known)_________________________________ Address: ____________________________________________________ _____________________________________________________ Telephone: ___________________________________________________ Facsimile: ____________________________________________________ 7. Effective Date of Initial Payment, Modification, Suspension, Termination or Controversion:______/______/20_____ 8. Description of Injury/Occupational Disease: ________________________________________________________ _____________________________________________________________________________________________ 9. Average Weekly Wage: $__________________ 10. Payment/Modification (check one): Initial Payment ____ Modification____ Workers' Compensation and/or Medical Benefits are to be paid as follows: A. B. PTD/TTD (circle one) benefits at the rate of $_____________ per week; SEB paid at the rate of $___________ per ___________ based on a wage earning capacity of $___________; or SEB paid at the rate of$ _________ per _________ dependent on wages as reflected in LWC-WC-1020's to be submitted by employee each month; Reduced PTD/TTD/SEB (circle one) at the rate of $___________ due to employee's receipt of (check applicable item): _____ Social Security Benefits at the rate of $______________ per _____________; _____ Other Workers' Compensation Benefits at the rate of $__________ per _________' _____ Employer Funded Disability Benefits at the rate of $___________ per __________; _____ Unemployment Insurance Benefits _____ Third Party Recovery in the amount of $_______________ _____ 50% reduction of compensation based on Employee's refusal to cooperate with Vocational Rehabilitation _____ Other (Describe): _________________________________________________________ _______________________________________________________________________ D. PPD Benefits of $______________ per week payable for ____________ weeks. E. Death Benefits have begun in the amount of $ _________ per week, representing ______% of AWW. C. American LegalNet, Inc. www.FormsWorkFlow.com 11. Suspension/Termination Workers' Compensation and/or Medical Benefits have been suspended/terminated due to: _____ Employee's refusal to submit to a medical examination; _____ Employee's refusal to execute a Choice of Physician form; _____ Fraud _____ Dispute over Compensability (Describe): ______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _____ Employee's refusal to return the form LWC-WC-1025 or LWC-WC-1020 _____ Other (Describe): ________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 12. Controversion Employee's rights to Workers' Compensation and/or Medical Benefits are disputed and have been denied because Employer/Payor disputes: _____ Compensable Work Accident; _____ Compensable Injury _____ Employment Relationship _____ Causation _____ Disability _____ Fraud _____ Jurisdiction _____ Other (Describe): _________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 13. Notice Submitted By: Payor: _______________________________ Name: _______________________________ Telephone:____________________________ Facsimile:_____________________________ Address: _____________________________ ______________________________ Employer: __________________________ Name :_____________________________ Telephone:__________________________ Facsimile: ___________________________ Address: ___________________________ ____________________________ Employer/Payor NCCI Number: _______________________ Signature of Preparer _____________________________________________ Printed name: ___________________________________________________ Position/Affiliation: _______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF DISAGREEMENT (to be completed by Employee/Employee Representative) MAIL TO: Employer/Payor at the address Listed on the LWC-WC-1002 Employee Social Security No.: _______-____-________ Payor Claim No. (if known): ___________________________ Date of Injury/Illness: _______________________________ Date of Notice of Disagreement: ______________________ BASIS OF DISAGREEMENT 1. 2. 3. 4. Average Weekly Wage is incorrect. The correct AWW amount is $______________. The type of workers' compensation indemnity benefits is incorrect. The correct type is PTD/TTD/SEB/PPD (circle one). The amount/rate of workers' compensation indemnity benefits is incorrect. The correct amount is $_________ per __________. The basis for Employer/Payor's suspension/termination/controversion of benefits is incorrect because (describe): ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Other (describe): ________________________________________________________________________ ______________________________________________________________________________________ ________________________
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