Maine > Workers Compensation
Providers Petition For Payment Of Medical And Related Services WCB-190A - Maine
| Providers Petition For Payment Of Medical And Related Services Form. This is a Maine form and can be used in Workers Compensation . |
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PROVIDER'S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES ' STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 HEALTH CARE PROVIDER NAME: EMPLOYER ) NAME: _____________________________________________________ STREET/P.O. BOX: __________________________________________ ) STREET/P.O. BOX: ) CITY, STATE, ZIP: ___________________________________________ CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ ) INSURANCE COMPANY EMPLOYEE NAME: __________________________________________ ) EMPLOYEE SOCIAL SECURITY NUMBER: XXX-XX-________________ ) NAME: _____________________________________________________ DATE OF INJURY: ___________________________________________ ) STREET/P.O. BOX: __________________________________________ BOARD FILE NUMBER: ________________________________________ ) CITY, STATE, ZIP: ___________________________________________ (IF KNOWN) 1. On MONTH DAY Y EAR , EMPLOYEE NAME experienced a work-related injury while working for EMPLOYER NAME . 2. The charges for medical and related services in connection with this injury amount to: $________________________. ATTACH COPIES OF ALL BILLS WHEREFORE, the health care provider asks the Board to order payment of the attached work-related medical bills and services pursuant to 39-A M.R.S.A. __________________________________________________________ SIGNATURE OF HEALTH CARE REPRESENTATIVE DATED:____________________________________________________ MONTH DAY YEAR FILING INSTRUCTIONS 1. 2. 3. 4. Mail original petition to the Workers Compensation Board at the above address by regular mail. Mail one (1) copy by certified mail, return receipt requested to the insurance company. Mail one (1) copy by certified mail, return receipt requested to the employer. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. __________________________________________________________ NAME OF PROVIDER'S ATTORNEY (IF ANY) __________________________________________________________ STREET/P.O. BOX __________________________________________________________ CITY, STATE, ZIP THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS' COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087 OR TTY Maine Relay 711. WCB-190A (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com
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