Medical Provider Application For Payment Or Reimbursement Of Medical Payment printable pdf download

Medical Provider Application For Payment Or Reimbursement Of Medical Payment

MEDICAL PROVIDER APPLICATION FOR

State of New Jersey

CASE NO’S.: ___________________________

Department of Labor and Workforce Development

PAYMENT OR REIMBURSEMENT OF

Division of Workers’ Compensation

MEDICAL PAYMENT

VICINAGE:

___________________________

PO Box 381

□

Trenton, NJ 08625-0381

**please enter above only if filing an Amended Claim**

NEW FILING

AMENDED FILING

WC-381 r. 8/26/2015

TAX IDENTIFICATION NUMBER:

NAME:

ADDRESS:

TELEPHONE NUMBER:

TELEPHONE NUMBER :

FAX NUMBER:

NAME:

NAME :

IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE BELOW:

ADDRESS:

CARRIER CLAIM NUMBER:

INDICATE THE STATUS OF THE EMPLOYER:

□

INSURED

UNINSURED

SELF-INSURED (PRIVATE)

SELF-INSURED (GOVT. AGENCY.)

□

IF UNINSURED, INDIVIDUAL CORPORATE OFFICERS ARE ALSO NAMED AS

Note:

RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS.

Corporations must be represented by counsel in

Workers’ Compensation Proceedings

SOCIAL SECURITY NUMBER:

□

SSN Not Available

NAME:

ADDRESS:

The injured worker

has

has not filed a Workers’ Compensation Claim

Petition related to this injury.

Claim Petition #:

DATE OF BIRTH:

SEX:

TO THE DIVISION OF WORKERS’ COMPENSATION

Applicant, alleging that the Employee sustained an injury by an accident arising out of and in the course of his / her employment with Respondent,

compensable under R.S. 34:15-7 et seq., supplements and amendments, respectfully states:

Date of Accident or Injury(required):

Date of Last Treatment:

Occupational Exposure

Occupation:

Diagnosis:

History of Accident or Illness:

Date(s) of Treatment:

Date Billed:

Amount Billed:

Amount Paid:

See attached for additional treatment

Medical Provider Application For Payment Or Reimbursement Of Medical Payment

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