Form 19 Request For Payment Of Charges For Health Or Rehabilitation Services

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THIS SPACE FOR COURT USE ONLY

FORM 19

COURT OF EXISTING CLAIMS

1915 NORTH STILES AVENUE

Send Original to

OKLA. CITY, OK 73105-4918

Court of Existing Claims and 1 copy to

Insurance Carrier, Self-Insured Employer/Own Risk

Group or Uninsured Employer

In re claim of:

Please check (

)

Full Name of Injured Employee (Claimant)

the appropriate box

Employee’s Social Security Number (LAST 4 DIGITS ONLY)

I . REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR

XXX-XX-____________________________

REHABILITATION SERVICES

Name of Employer (Respondent)

I I . NOTICE OF APPEAL OF COURT ADMINISTRATOR ORDER

Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or

Own Risk Group, Uninsured

WCC FILE NO.

(Must be filled out)

Name of Provider

Date of Injury

(Please type or print)

Address of Employee (Claimant) Including Number & Street

City

State

Zip

Address of Employer (Respondent) Including Number & Street

City

State

Zip

Address of Provider Including Number & Street

City

State

Zip

Provider’s Telephone Number

NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free

(800) 522-8210.

If the Form 19 is being filed to appeal an order issued by the Administrator of the Court of Existing Claims, please complete PART II ONLY.

- PART I. REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES

Total expenses to date for services rendered or medicines or supplies provided to claimant $ ____________________________________________________________

Date charges identified above were submitted to the claimant’s self-insured employer, uninsured employer or the employer’s workers’ compensation insurance carrier

(MUST be completed).

__________________________, ________.

Total Amount Received in Payment $________________________.

If the dispute involves the length of treatment rendered, or relates to complex medical treatment rendered beyond applicable treatment guidelines, a narrative medical report explaining

the treatment provided and the charges submitted, must be sent to the payer. DO NOT ATTACH A COPY OF ANY BILLS OR MEDICAL REPORTS WHEN FILING THE FORM 19

WITH THE COURT OF EXISTING CLAIMS.

- PART II. NOTICE OF APPEAL OF COURT ADMINISTRATOR ORDER

File stamped date of Administrator’s Order: ___________________________, ____________.

Identify each portion of the Administrator’s Order which is claimed in error and how it conflicts with the Schedule of Medical and Hospital Fees:

________________________________________________________________________________________________________________________

I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true,

correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony.

I HEREBY CERTIFY THAT A COPY OF THIS FORM AND

Signed this _______ day of ____________________________, ___________

ALL RELEVANT BILLS AND MEDICAL REPORTS HAVE

BEEN SENT TO:

Signature of Provider