Employees Application For Additional Medical Compensation {18M} | Pdf Fpdf Doc Docx | North Carolina

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Employees Application For Additional Medical Compensation {18M} | Pdf Fpdf Doc Docx | North Carolina

Employees Application For Additional Medical Compensation {18M}

This is a North Carolina form that can be used for Workers Comp.

Alternate TextLast updated: 3/30/2016

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North Carolina Industrial Commission IC File # EMPLOYEE'S APPLICATION FOR ADDITIONAL MEDICAL COMPENSATION (G.S. § 97-25.1) (APPLICABLE TO INJURIES BY ACCIDENT OR OCCUPATIONAL DISEASES CONTRACTED ON OR AFTER 5 JULY 1994) The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Emp. Code # Carrier Code # Employer FEIN . ( Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address ) Telephone Number City State Zip ( ) M F ( / ) City State Fax Number Zip Home Telephone Social Security Number Sex Work Telephone / ( ) ( ) Date of Birth Carrier's Telephone Number SECTION A. TO BE COMPLETED BY EMPLOYEE: 1. The above-named employee claims additional medical compensation as a result of an injury by accident or an occupational disease which occurred on or by (Date) because (Reason for Additional Medical Compensation) Additional medical and/or other supporting documentation is / is not attached (optional). (Place your I.C. File # on each attachment.) 2. SIGNATURE OF EMPLOYEE Name and address of employee's attorney, if any: DATE COMPLETED EMPLOYEE: SEND THE ORIGINAL OF THIS FORM AND ANY SUPPORTING DOCUMENTATION TO THE INDUSTRIAL COMMISSION AS INSTRUCTED AT THE BOTTOM OF THIS FORM AND SEND A COPY TO THE EMPLOYER OR CARRIER/ADMINISTRATOR. SECTION B. TREATING PHYSICIAN'S STATEMENT (OPTIONAL) : This is to certify that: , 1. I am the above-named employee's treating physician. My area of medical practice is and my treatment of the employee began on . (mo/day/yr) 2. In my opinion, there is a substantial risk that the employee will need the following additional medical care or monitoring (including medical, surgical, hospital, nursing, rehabilitation services, medicines, sick travel, replacement of artificial members, medical and surgical supplies, and other treatment): . The need for this medical treatment results from the injury by accident or occupational disease as set forth in Section A. above. SIGNATURE OF TREATING PHYSICIAN ADDRESS PRINTED NAME CITY STATE DATE ZIP ATTORNEYS/CARRIERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML FORM 18M FORM 18M 02/2016 PAGE 1 OF 1 EMPLOYEE FILING OPTIONS: E-MAIL TO EXECSEC@IC.NC.GOV FAX TO (919) 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV American LegalNet, Inc. www.FormsWorkFlow.com

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