South Dakota > Workers Compensation
Petition For Hearing On Medical Benefits - South Dakota
| Petition For Hearing On Medical Benefits Form. This is a South Dakota form and can be used in Workers Compensation . |
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SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION DIVISION OF LABOR AND MANAGEMENT , Petitioner, vs. PETITION FOR HEARING ON MEDICAL BENEFITS , Employer, and , Insurer. , Petitioner, makes claim against , Employer, and , Insurer, and respectfully alleges, to Petitioner's best knowledge, information and belief: 1. That the Petitioner provided medical services to Employee, on or about the day(s) of 2. That the Employer was insured with the Insurer under South Dakota's workers' compensation law on the dates these services were provided. 3. That Petitioner believes the Employee suffered an injury, disease or hearing loss which arose out of and in the course of Employee's employment with Employer. 4. American LegalNet, Inc. www.FormsWorkFlow.com , , 20 . That the Petitioner seeks additional reimbursement for the following costs/services (attach additional information if necessary): 5. That, in the Petitioner's professional opinion, those costs/services were reasonable and necessary for the treatment of the Employee's injury and resulting condition. WHEREFORE, the Petitioner prays that the Division of Labor and Management require Employer/Insurer to pay the medical expenses to which the Petitioner is entitled under South Dakota workers' compensation law. Dated this day of , 20 . Petitioner's name, address, and phone number: 2 American LegalNet, Inc. www.FormsWorkFlow.com
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