Form 10m - Response To Request For Payment Of Charges For Health Or Rehabilitation Services

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FORM 10M

COURT OF EXISTING CLAIMS

THIS SPACE FOR COURT USE ONLY

1915 NORTH STILES, STE 127

Send original to

OKLA.CITY, OKLAHOMA 73105-4918

Court of Existing Claims and 1 copy to

Claimant/Claimant’s Counsel and 1 copy to

Health/Rehabilitation Provider

In re claim of:

Full Name of Injured Employee (Claimant)

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

XXX-XX-__________________

Name of Employer (Respondent)

RESPONSE TO REQUEST FOR PAYMENT OF CHARGES FOR

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

HEALTH OR REHABILITATION SERVICES

Own Risk Group, Uninsured

Name of Claiming Provider

WCC FILE NO.

Date of Injury

(Must be filled out)

Provider’s Address

(Please Type or Print)

Address of Employee (Claimant):

Number & Street

City

State

Zip Code

Address of Employer (Respondent):

Number & Street

City

State

Zip Code

NOTE: Mediation is available to address certain workers’ compensation disputes.

For information, call (918) 581-2714.

YES

1. Has payment been refused?

________ ________

2. Grounds for the refusal of payment?

a. necessity of treatment rendered.

________ ________

b. unauthorized physician.

________ ________

c. denial of compensability of the claimant’s accidental injury or occupational disease.

________ ________

d. other, including affirmative defenses (explain)____________________________________________________________________

________ ________

3. Was provider notified of refusal of payment within 45 days?

________ ________

4. Has an order from the Court of Existing Claims been issued regarding the compensability of the claimant’s request for

________ ________

compensation? Date of order __________________________________________________________________________________

5. Has the claimant’s request for benefits been resolved by Settlement or Agreement of the parties?

________ ________

Date of Settlement or Agreement ________________________________________________________________________________

6. Has claimant been provided Temporary Total Disability benefits? Date TTD benefits provided: _______________to______________

________ ________

7. List all other medical providers in this claim which are in dispute: Medical/Rehabilitation Provider______________________________________________

__________________________________________________________________________________________________________________________

8. List the names of all witnesses who may be called by respondent at trial: ________________________________________________________________

__________________________________________________________________________________________________________________________

9. List all exhibits to be introduced at trial: ___________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

If the dispute involves the length or necessity of treatment rendered, or relates to complex medical treatment rendered beyond applicable treatment

guidelines, a narrative medical report opposing the treatment provided and/or the charges submitted must be sent to the health/rehabilitation

provider. Do NOT attach a copy of the medical report when filing the Form 10M with the Court of Existing Claims.

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.

Signed this________________day of______________________,___________.

Signature of Responding Party

I HEREBY CERTIFY THAT A COPY OF THIS FORM AND ALL

RELEVANT MEDICAL REPORTS HAVE BEEN SENT TO:

Claimant

Health/Rehabilitation Provider

Address (Number & Street)

City

State

Zip Code

Telephone # of Responding Party