Medical Provider Application For Payment Or Reimbursement Of Medical Payment (Page 2 of 2) in pdf

Medical Provider Application For Payment Or Reimbursement Of Medical Payment Page 2

What other facts are there that you believe important?

Summary of Changes (Complete only if filing an Amended pleading):

The Applicant therefore requests that the Division of Workers’ Compensation determine the amount of payment due from said

Respondent, under Revised Statutes of New Jersey, Title 34, Chapter 15, and the acts supplemental thereto and amendatory thereof,

and that your Applicant may be awarded costs in this proceeding, and such other or further relief as may be proper.

Applicant

STATE OF NEW JERSEY

COUNTY OF ________________________

Subscribed and sworn or affirmed

to before me this _______ day of __________________ , 20_____

____________________________________________

This Application has been presented by the service provider to the Division of Workers’ Compensation for hearing and determination.

Unless an Answer is filed within 30 days of the date of service of the Applicant upon you, with the assignment clerk at the vicinage to

which the claim is assigned as indicated on the reverse side, and a copy served upon the attorney, THE APPLICANT WILL PROCEED

WITH PROOF OF CLAIM ACCORDING TO LAW AND MAY OBTAIN JUDGMENT AGAINST YOU.

The Privacy Act, 5 U.S.C. §552a, the Social Security Act, 42 U.S.C. §405, and N.J.S.A. 34:15-1 et seq. authorize the Division of

Workers’ Compensation to request that the Applicant supply the Division with the employee’s Social Security number for record keeping

purposes and cross-matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any

other proper public purpose.

Medical Provider Application For Payment Or Reimbursement Of Medical Payment Page 2