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Application For Adjustment Of Claim For Provider Fee 18487 - Indiana
|Application For Adjustment Of Claim For Provider Fee Form. This is a Indiana form and can be used in General Workers Compensation .||
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APPLICATION FOR ADJUSTMENT OF CLAIM FOR PROVIDER FEE State Form 18487 (R6 / 5-11) Approved by State Board of Accounts, 2011 WORKERS COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204-2753 Telephone: (317) 232-3808 INSTRUCTIONS: 1. The applicant must file an original and two (2) copies of this application for it to be processed. 2. Mail to the Workers Compensation Board at the above address. 3. For detailed instructions, go to www.in.gov/wcb/files/Provider_Memo.pdf. PLAINTIFF vs DEFENDANT FOR STATE USE ONLY Application number Name of plaintiff (provider) Address (number and street) City, state, and ZIP code Telephone number Federal identification number Name of defendant (employer) Address (number and street) City, state, and ZIP code Telephone number Federal identification number Insurance claim number ( ) ( ) Name of attorney (must complete) Address (number and street) City, state, and ZIP code Telephone number E-mail address vs Name of insurance carrier Address (number and street) City, state, and ZIP code Name of adjuster Telephone number ( ) Attorney number ( ) E-mail address Billing review company Must check one: Total Billing (no payment received) Balance Billing (partial payment received) Single Bundled For Balance Billing (A $60.00 filing fee must accompany the application.): Check number: ______________________________________________ Name of reviewer Telephone number E-mail address ( ) THE PLAINTIFF RESPECTFULLY REPRESENTS TO THE BOARD AS FOLLOWS: That the defendants, as employer and employers compensation insurance carrier, owe and are indebted to the plaintiff on account in the sum of ___________________________________________________________________________________________ dollars for providers fee and supplies in the treatment of the injuries of ____________________________________________________________ Name of patient incurred as a result of an injury / illness arising out of and in the course of the employment with the defendant employer, on the ________ day of ______________________________, 20______, in the county of _________________________________. The patients date of birth is (month, day, year): _______________________________ The patients address is (number and street, city, state, and ZIP code): ________________________________________________________ Latest date of service (month, day, year): ____________________________________ That said services were rendered as follows (check all that apply): In an emergency The employee was in need of timely services provided The employer failed to provide such service Employer or insurance carrier approved such services Provider first requested payment for said services on (month, day, year): ____________________________________ The applicant certifies that required diligence has been accomplished and that the initial written response from the employer / representative was received on (month, day, year): ___________________________ Additional date(s) demands made (month, day, year): ___________________________________________________________________ Date(s) of follow-up (month, day, year): ______________________________________________________________________________ Type of second request: Signature of plaintiff Oral E-mail Written Date(s) (month, day, year):_______________________________ Date signed (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com Wheretofore the plaintiff prays to the Board to find against the defendant on said account the sum of $ __________________________.