Medical Treatment Statement Supplies And Medications {WKC-3}

WKC-3 - MEDICAL TREATMENT STATEMENT SUPPLIES AND MEDICATIONS. This form is used by the Wisconsin Department of Workforce Development's Worker’s Compensation Division to document medical-related expenses in a worker’s compensation claim. The form must be completed prior to a scheduled prehearing conference and updated before the formal hearing. It requires the claimant to list all providers of medical treatment, medications, or supplies, along with the total charges, amounts paid by the applicant or other insurance carriers, and any remaining unpaid balances. An itemized statement supporting each expense must be attached and shared with both the Division and other involved parties at least 15 days before the hearing, in compliance with Wisconsin Statute §102.17(8). The form also collects claim and injury information, as well as details about Social Security and Medicare coverage if applicable. While providing a Social Security Number is voluntary, not doing so may delay processing. The information gathered helps ensure accurate handling and adjudication of medical expense claims under Chapter 102 of the Wisconsin Statutes governing worker’s compensation. www.FormsWorkflow.com