Medicare Conditional Payment Addendum (Judgment) | Pdf Fpdf Doc Docx | New Jersey

 New Jersey /  Workers Comp /  Settlement /
Medicare Conditional Payment Addendum (Judgment) | Pdf Fpdf Doc Docx | New Jersey

Medicare Conditional Payment Addendum (Judgment)

This is a New Jersey form that can be used for Settlement within Workers Comp.

Alternate TextLast updated: 8/1/2011

Included Formats to Download
$ 13.99

Description

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION MEDICARE CONDITIONAL PAYMENT ADDENDUM (JUDGMENT) CASE NUMBER(S) : VICINAGE: Petitioner: Respondent: Petitioner is Medicare entitled. The Center for Medicare Services (CMS) has been contacted for an itemization of monies, if any, CMS paid for the compensable condition(s). As of this date, the CMS conditional payment review is pending. All parties agree that should they not be able to amicably resolve the responsibility for reimbursement to CMS, this Court retains jurisdiction to determine the extent to which the respondent is liable for payment to CMS for medical treatment. All parties recognize that this court has no jurisdiction to determine the total amount due CMS. _______________________________________________________________________ JUDGE OF COMPENSATION DATE WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE A COPY _____________________________________________________________ PETITIONER'S ATTORNEY _________________________________________________________ RESPONDENT'S ATTORNEY _____________________________________________________________ PETITIONER (Where Applicable) WC- American LegalNet, Inc. www.FormsWorkFlow.com

Our Products