Minnesota > Workers Comp
Annual Claim For Reimbursement From Secondary Injury Fund AR04 - Minnesota
| Annual Claim For Reimbursement From Secondary Injury Fund Form. This is a Minnesota form and can be used in Workers Comp . |
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Mail completed copy to: Annual Claim for Reimbursement Department of Labor and Industry Special Compensation Fund from the AR 0 4443 Lafayette Road North St. Paul, MN 55155 Second Injury Fund FOR SCF USE ONLY (651) 284-5045 or Please PRINT OR TYPE your responses 1-800-342-5354 (DIAL-DLI) All dates must be entered in MM/DD/YYYY Fax: (651) 284-5733 SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE NAME INSURER/SELF-INSURE R (Reimbursement Payable To) EMPLOYER NAME INSURER/ ADDRESS INSURER CLAIM NUMBER CITY STATE ZIP CODE Claim status A. First claim for this date of injury AA. First and last claim based upon full, final and complete settlement B. Continuing - Attach EVIDENCE of contact with employee during the time period which SUPPORTS ELIGIBILITY for benefits (i.e., status check confirmi ng employee remains disabled , medical and/or rehabilitation reports from the time period claimed, etc.). C. Final Claim for this case. Reason: 1) Returned to work on: _______________________ 2) Death of employee on: _______________________ ATTACH DEATH CERTIFICATE 3) Indemnity and/or medical closed by settlement 4) Other: Explain: YOU MUST COMPLETE THE BACK SIDE OF THIS FORM. Name of Preparer Date Company Name (if different from above) Phone No. (include area code & ext.) Address ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIV ES WORKERS COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTIN G, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. MN AR04 (8/03) <<<<<<<<<********>>>>>>>>>>>>> 2 MEDICAL AND REHABILITATION EXPENSE DETAIL Attach detailed description/itemization of rehabilitation and/or medical expenses. Include the dates of service, dates paid, a mounts paid and names of providers. (Computerized printouts are sufficient if they include all required information.) These medical expenses do NOT exceed DO exceed permissible limits set for medical services in Minnesota Rules Chapter 5221. If the medical fee schedule has not been applied to any bills for medical services, ATTACH A COPY OF THE BILL SHOWING THE CPT CODE. DATES for which you are requesting reimbursement through 1. a. Medical and rehabilitation expenses claimed this period b. Less deductible to this date of injury - SUBTOTAL c. Percent apportioned (Attach proof of apportionment if claiming for the first time) % SUBTOTAL d. Lump sum amount to be reimbursed e. TOTAL Medical and Rehabilitation expenses claimed $ INDEMNITY EXPENSE DETAIL Complete an Interim Status Report for the period covered by this claim. Transfer the information from the Interim Status Report. DATES for which you are requesting reimbursement through 2. a. Temporary Partial Benefits paid Retraining Benefits paid Temporary Total Benefits paid Permanent Total Benefits paid SUBTOTAL b. Less deductible to this date of injury - SUBTOTAL c. Percent apportioned (Attach proof of apportionment if claiming for the first time) % SUBTOTAL d. Permanent Partial, Impairment Co mpensation, Economic Recovery claimed (circle type of permanency paid) e. Lump sum to be reimbursed f. TOTAL indemnity reimbursement claimed $ 3. TOTAL reimbursement claimed (1e + 2f) $ SPECIAL COMPENSATION FUND USE ONLY Indemnity Amount Approved $ Medical Amount Approved $ Adjustment Code Amount Adjusted $ Approved by Total Approved $ Date Approved Paid by Date Paid Vendor Number Batch Number
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