Lwc Form 1010 - Request Of Authorization/carrier Or Self Insured Employer Response
Download a blank fillable Lwc Form 1010 - Request Of Authorization/carrier Or Self Insured Employer Response in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Lwc Form 1010 - Request Of Authorization/carrier Or Self Insured Employer Response with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2LWC FORM 1010 - REQUEST OF AUTHORIZATION/CARRIER OR SELF INSURED EMPLOYER RESPONSE
PLEASE PRINT OR TYPE
SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care Provider
Last Name:
First:
Middle:
Street Address, City, State, Zip:
P
A
T
Last 4 Digits of Social Security Number:
Date of Birth:
Phone Number:
Date of Injury:
I
E
Employers Name:
Street Address, City, State, Zip:
Phone Number:
N
T
C
Name:
Adjuster:
Claim Number (if known):
A
R
R
Street Address, City, State Zip:
Email Address:
Phone Number:
Fax Number:
I
E
R
SECTION 2. REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider
Requesting Health Care Provider:
Phone Number:
Fax Number:
P
Street Address, City, State Zip:
Email:
R
O
V
Diagnosis:
CPT/DRG Code:
ICD/DSM Code:
I
D
E
Requested Treatment or Testing (Attach Supplement If Needed):
R
Reason for Treatment or Testing (Attach Supplement If Needed):
INFORMATION REQUIRED BY RULE TO BE INCLUDED WITH REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider
(Following is the required minimum information for Request of Authorization (LAC 40:2715 (C))
History provided to the level of condition and as provided by Medical Treatment Schedule
Physical Findings/Clinical Tests
P
P
Documented functional improvements from prior treatment
R
O
Test/imaging results
V
I
Treatment Plan including services being requested along with the frequency and duration
D
Faxed
to the Carrier/Self Insured Employer on this the
E
R
I hereby certify that this completed form and above required information was
_____ day of ______ , ______
Emailed
(day)
(month)
(year)
Signature of Health Care Provider:
Printed Name:
SECTION 3. RESPONSE OF CARRIER/SELF INSURED EMPLOYER FOR AUTHORIZATION
(Check appropriate box below and return to requesting Health Care Provider, Claimant and Claimant Attorney as provided by rule)
The requested Treatment or Testing is approved
The requested Treatment or Testing is approved with modifications
(Attach summary of reasons and explanation of any modifications)
The requested Treatment or Testing is denied because
Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons)
The request, or a portion thereof, is not related to the on-the-job injury
The claim is being denied as non-compensable
Other (Attach brief explanation)
Faxed
to the Health Care Provider (and to the Attorney of
C
A
Claimant if one exists, if denied or approved with
R
modification) on this the
I hereby certify that this response of Carrier/Self Insured Employer for Authorization was
R
_____ day of ______ , ______
I
(day)
(month)
(year)
Emailed
E
R
Signature of Carrier/Self Insured Employer or Utilization Review Company:
Printed Name:
The prior denied or approved with modification request is now approved
to the Health Care Provider and Attorney of Claimant
Faxed
if one exists on this the
I hereby certify that this response of Carrier/Self Insured Employer for Authorization was
y
y
p
p y
_____ day of ______ , ______
_____ day of ______ , ______
(day)
(month)
(year)
Emailed
Signature of Carrier/Self Insured Employer or Utilization Review Company:
Printed Name:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 141 - Initial Statement Of Insurance Carrier Or Self-insurer With Respect To Payment Of Benefits
Legal
Form 115ar Report Of Procurement, Continuance, Or Renewal Of Insurance With Unauthorized Insurer - Connecticut
Business
Form 702 - Motor Fuel, Motor Carrier Or Tobacco Products License Surety Bond Form - Michigan Department Of Treasury
Financial
Form 115ar - Report Of Procurement, Continuance Or Renewal Of Insurance With Unauthorized Insurer
Financial
Form 115ar - Report Of Procurement, Continuance Or Renewal Of Insurance With Unauthorized Insurer
Financial
Related Categories
Parent category: Business