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Explanation Of Benefits DWC-62 - Texas

Explanation Of Benefits Form. This is a Texas form and can be used in Medical Workers Compensation .
 Fillable pdf Last Modified 12/28/2007
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TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS' COMPENSATION Distribution of this form will be in accordance with Rule 133.304 DO NOT SEND THIS FORM TO DWC UNLESS DWC SPECIFICALLY REQUESTS IT. An insurance carrier may substitute its own EOB form, but MUST obtain prior approval from DWC. CLAIM #_______________________________________ Carrier's Claim # ________________________________ EXPLANATION OF BENEFITS 1. Injured employee's name (Last, First, M.I.) 2. Injured employee=s Social Security number 3. Date of injury 4. Injured employee's mailing address (Street or P.O. Box) 5. Employer's name and address 6. Health care provider's name and address 7. Insurance carrier's name and address 8. Health care provider=s federal tax I.D. number 9. Name and address of the company performing the audit Insurance carrier payment to the health care provider shall be according to Division medical policies and fee guidelines in effect on the date(s) of service(s). Health care providers shall not bill any unpaid amounts to the injured employee or the employer, or make any attempt to collect the unpaid amount from the injured employee or the employer unless the injury is finally adjudicated not to be compensable, or the insurance carrier is relieved of liability under '408.024 of the Texas Workers' Compensation Act. Date of the audit: 10. Name and telephone number of the person who can be contacted about the bill reduction: DOS CPT / Rev Code Type of Service ICD-9 Code Units Charges Amount Paid Reason Code Reason for Reduction / Denial DOS: date of service PEC: payment exception code DWC FORM-62 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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