Arizona > Workers Comp
Self-Insured Medical Report - Arizona
| Self-Insured Medical Report Form. This is a Arizona form and can be used in Workers Comp . |
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SELF-INSURED MEDICAL REPORT FOR 2005 THE INDUSTRIAL COMMISSION OF ARIZONA Self-Insured: Period covered: to READ INSTRUCTIONS ON REVERSE SIDE ______________________________________________________________________________ 1. Costs relating to industrial injuries: 2. Amount paid to doctors, nurses, hospitals, etc., for outside services rendered. 3. Amount paid for medications (Rx"s and injections, etc.). 4. Amount paid for prosthetic devices (artificial limbs, braces, etc.). 5. Portion of hospital expenses shown on "Hospital Report" (line 11) for industrial injuries. (incurred not directly paid) 6. Remuneration of medical personnel employed by the selfinsured. 7. Amount paid for first aid supplies. 8. Total medical costs for industrial-related cases during calendar year. (TOTAL LINES 1 7) 9. Compensation paid to claimants. 10. Reinsurance premiums paid (for loss limit of $________). 11. Total expenditures for workmen's compensation and occupational disease claims (total of lines 8, 9, and 10). $ ___________ ___________ ___________ ___________ ___________ ___________ $ $ ___________ ___________ $ ______________________________________________________________________________ This report subject to verification by ICA auditors. I certify this report is a true and complete account of medical expenses for the period stated. Signature: Title: Date: American LegalNet, Inc. www.USCourtForms.com
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