Request For Additional Palliative Care {DWC-40}

State of Rhode Island REQUEST FOR ADDITIONAL PALLIATIVE CARE Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 Medical Provider complete 1-7 PLEASE CHECK IF CORRECTION OF PRIOR REPORT DWC No. Insurer File No. Phone (401) 462-8100 TDD (401) 462-8006 You must send this request to the claim administrator at least ten (10) working days prior to the delivery of services, with a copy to the employee. 1. EMPLOYEE: SSN Name Address City, State, Zip Phone 2. EMPLOYER: FEIN Name Address City, State, Zip Phone Date of Birth (Party managing the claim ex: Insurer) Ext. 3. CLAIM ADMINISTRATOR: FEIN Name Address City, State, Zip Phone 4. MEDICAL PROVIDER: FEIN Name Address City, State, Zip Phone Date maximum medical improvement (MMI) reached: Ext. Ext. 5. INJURY INFORMATION: Injury date: 6. DATE INFORMATION: Date of this request: Date delivery of service is planned: 7. TREATMENT PLAN INFORMATION: (If necessary, attach additional pages) Treatment Plan: Measures to Evaluate Objectives: Timetable and Projected End Date: Estimated Total Cost of Services: Medical Provider Signature: Date: Claim Administrator Complete: 8. Request for Additional Palliative Care has been: Approved Modified Denied 9. Treatment plan has been modified or denied for the following reason(s): Print Adjuster Name: Date: A copy of this completed form shall be forwarded by the claim administrator to the RI Department of Labor and Training, Division of Workers' Compensation, and the employee and his or her attorney within ten (10) working days of the request for additional palliative care. Either party has a right to a review of any decision regarding additional palliative care by the Workers' Compensation Court, pursuant to RIGL §28-35-11. DWC-40 (04/05) American LegalNet, Inc. www.USCourtForms.com