Form 18m - Employee'S Application For Additional Medical Compensation
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1North Carolina Industrial Commission
IC File #
E
’
A
A
M
MPLOYEE
S
PPLICATION FOR
DDITIONAL
EDICAL
Emp. Code #
C
(G.S. § 97-25.1)
OMPENSATION
Carrier Code #
(A
I
A
O
D
PPLICABLE TO
NJURIES BY
CCIDENT OR
CCUPATIONAL
ISEASES
Employer FEIN
A
5 J
1994)
CONTRACTED ON OR
FTER
ULY
The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act
.
(
)
Employee’s Name
Employer's Name
Telephone Number
Address
Employer’s Address
City
State
Zip
City
State
Zip
Insurance Carrier
(
)
(
)
Home Telephone
Work Telephone
Carrier's Address
City
State
Zip
(
)
(
)
XXX-XX-
M
F
/
/
Last 4 Digits of SSN
Sex
Date of Birth
Carrier's Telephone Number
Fax Number
S
A. T
C
E
:
ECTION
O BE
OMPLETED BY
MPLOYEE
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)
2.
Additional medical and/or other supporting documentation
is
/
is not attached (optional).
(Place your I.C. File # on each attachment.)
S
O
E
D
C
IGNATURE
F
MPLOYEE
ATE
OMPLETED
Name and address of employee's attorney, if any:
E
: S
I
C
MPLOYEE
END THE ORIGINAL OF THIS FORM AND ANY SUPPORTING DOCUMENTATION TO THE
NDUSTRIAL
OMMISSION
/
.
AS INSTRUCTED AT THE BOTTOM OF THIS FORM AND SEND A COPY TO THE EMPLOYER OR CARRIER
ADMINISTRATOR
S
B. T
P
'
S
(OPTIONAL) :
ECTION
REATING
HYSICIAN
S
TATEMENT
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.
S
O
T
P
P
N
D
IGNATURE
F
REATING
HYSICIAN
RINTED
AME
ATE
A
C
S
Z
DDRESS
ITY
TATE
IP
A
/C
:
TTORNEYS
ARRIERS
F
E
D
F
P
ILE VIA
LECTRONIC
OCUMENT
ILING
ORTAL
://
.
.
.
/
.
HTTP
WWW
IC
NC
GOV
DOCFILING
HTML
E
F
O
:
MPLOYEE
ILING
PTIONS
F
18M
ORM
E-
@
.
.
MAIL TO EXECSEC
IC
NC
GOV
02/2017
F
(919) 715-0282
F
18M
AX TO
ORM
M
NCIC-E
S
P
1
1
AIL TO
XECUTIVE
ECRETARY
AGE
OF
4333 M
S
C
AIL
ERVICE
ENTER
R
, NC 27699-4333
ALEIGH
H
: (800) 688-8349
ELPLINE
W
:
://
.
.
.
EBSITE
HTTP
WWW
IC
NC
GOV
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