COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.BobTaft GovernorJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)JamesConrad Administrator/CEOThe Ohio Bureau of Workers Compensation 30 West Spring Street, Columbus Ohio 43215-2256. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REQUESTFORTHEOHIOBUREAUOFWORKERSCOMPENSATION 2003FEESCHEDULETHE PEOPLE OF THE STATE OF NEW YORK TOEffective for dates of service on or fter Jan 1, 2003, BWC will require 2003 CPT Billing Codes. With the requirement of 2003 CPT Billing Codes, BWC will also implement fee schedule for HCPCS Level I (CPT), HCPCS Level II, and HCPCS Level III (Local) Codes. To obtain a copy of BWCs 2003 Fee Schedule, complete the information below.Company/BusinessGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Contact Person Physical Address (cannot mail to P.O Box) City, State, ZIP Code Telephone Number Fax Numberlocated at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.2003FEESCHEDULEThe 2003 Fee Schedule is available in two formats. Check the format you wish to receive.Booklet (Hard Copy)$10 per copy, one of the Justices of theDownloadable diskette$10 per copy*Court in Witness, Honorableday of, 20 County,* The downloadable diskette requires a signed CPT end user agreement between BWC and the requestor prior to distribution. Upon receiving the completed fee schedule application, BWC will send the end user agreement to the requestor. Requestor must sign and return end user agreement, long with the $10 fee to BWC.(Attorney must sign above and type name below)Attorney(s) forWhen ordering, please enclose a check for the appropriate amount. Make the check payable to OhioBureauof WorkersCompensation. Please complete this form and return with check to BWCs Policy and Support department at:OhioBureauofWorkersCompensation PolicyandSupportL-20 30WestSpringStreet Columbus,OH 43215-2256Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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