Wisconsin > Workers Comp
Medical Treatment Statement Supplies And Medications WKC-3 - Wisconsin
| Medical Treatment Statement Supplies And Medications Form. This is a Wisconsin form and can be used in Workers Comp . |
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MEDICAL TREATMENT STATEMENT SUPPLIES AND MEDICATIONS Complete this form before the prehearing conference (if one is scheduled) and update it before the formal hearing. Bring this form to both the conference and hearing. Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.wisconsin/wc e-mail: DWDDWC@dwd.wisconsin.gov NOTE: An itemized statement for each expense claimed must be attached to this form and provided to the Worker's Compensation Division and other parties to this case at least 15 days before the hearing, according to section 102.17(8) of the statutes. Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. WC Claim Number Employee Name Employee Social Security Number Injury Date Employer Name Insurance Company Name Names of Providers of Treatment, Medication, or Supplies Total Charges Amount Paid By Applicant Amount Paid By Other Insurance Carriers (Give Carriers' Names) Unpaid Balance TOTAL: WKC-3 (R. 07/2009) American LegalNet, Inc. www.FormsWorkFlow.com
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