La. Admin. Code tit. 40 § I-2328

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Current through Register Vol. 50, No. 9, September 20, 2024

Section I-2328 - LWC-WC 1009. Disputed Claim for Medical Treatment

E-Mail to: medicalservices@LWC.la.gov

Fax to: OWCA - Medical Services 1. Social Security No. __-__-__

ATTN: Medical Director 2. Date of Injury/Illness __-__-__

(225) 342-6556 3. Parts of Body Injury_________

Mail to: Medical Services 4. Date of Birth __-__-__

P.O. Box 94040 5. Date of This Request __-__-__

Baton Rouge, LA 70804 6. Claim Number ____________

DISPUTED CLAIM FOR MEDICAL TREATMENT

NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS THERE ARE MEDICAL SERVICES IN DISPUTE AS PER R.S. 23:1203.1 J AND THE FOLLOWING HAS OCCURRED:

A. The insurer has issued a denial.

B. The insurer has issues an approval with modification.

C. The insurer's failure to act has resulted in a deemed denial.

D. The aggrieved party is seeking a variance from the medical treatment schedule

DISPUTES RELATING TO COMPENSABILITY AND/OR CAUSATION ARE NOT ADDRESSED BY THE MEDICAL DIRECTOR.

GENERAL INFORMATION

Claimant files this dispute with the Office of Workers' Compensation Medical Services Director. This office must be notified immediately in writing of changes in address. An employee may be represented by an attorney, but it is not required.

7. This request is submitted by

___ Employee ____ Health Care Provider ___ Other ________________

The following records/documents MUST be attached to this request. Failure to do so may result in the rejection of the request by the OWCA director:

A. Copies of all relevant information must be included with this request as per LAC 40:I.2715 J.

B. If applicable, a copy of the denial letter issued by the insurance carrier must be attached to this request.

C. A copy of this request with all supporting documentation must be mailed or emailed to all parties at their designated fax or email address.

EMPLOYEE	EMPLOYEE'S ATTORNEY
8. Name ___________________	9. Name __________________
Street or Box _______________	Street or Box ______________
City ______________________	City _____________________
State __________ Zip _______	State ________ Zip _________
Phone (____) ______________	Phone (____) ______________
Fax (____) ______________

EMPLOYER	INSURER/ADMINISTRATOR
	(circle one)
10. Name __________________	11. Name _________________
Street or Box _______________	Street or Box ______________
City ______________________	City _____________________
State __________ Zip _______	State ________ Zip _________
Phone (____) ______________	Phone (____) ______________
Fax (____) ______________	Fax (____) ______________

TREATING/REQUESTING

PHYSICIAN

12. Name __________________

Street or Box _______________

City ______________________

State __________ Zip _______

Phone (____) ______________

Fax (____) ______________

13. PLEASE PROVIDE A SUMMARY OF THE DETAILS REGARDING THE ISSUE AT DISPUTE:

__________________________________________________________

You may attach a letter or petition with additional information with this disputed claim.

By signing below, you are certifying that this form along with all supporting documentation has been sent to the carrier/self-insured employer this date to their designated fax or email address.

The information given above is true and correct to the best of my knowledge and belief.

___________________________________ __________________

SIGNATURE OF REQUESTING PARTY DATE

___________________________________

Printed Name of Requesting Party

LWC-WC 1009

11/2010

La. Admin. Code tit. 40, § I-2328

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 38:3254 (December 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.