Employees Application For Additional Medical Compensation {18M}

FORM 18M 10/2017 PAGE 1 OF 1 A TTORNEYS/CARRIERS: FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP://WWW.IC.NC.GOV/DOCFILING.HTML EMPLOYEE FILING OPTIONS: E-MAIL TO EXECSEC@IC.NC.GOV FAX TO (919) 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 HELPLINE: (800) 688-8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOV FORM 18M North Carolina Industrial Commission IC File # E MPLOYEE222S APPLICATION FOR ADDITIONAL MEDICAL Emp. Code # COMPENSATION (G.S. 247 97-25.1) Carrier Code # (APPLICABLE TO INJURIES BY ACCIDENT OR OCCUPATIONAL DISEASES Employer FEIN CONTRACTED ON OR AFTER 5 JULY 1994) . The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act ( ) Employee222s Name Employer's Name Telephone Number A ddress Employer222s Address City State Zip City State ZipInsurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number SECTION A. TO BE COMPLETED BY EMPLOYEE: 1. The above-named emplo y ee claims additional medical compensation as a result of an in j ur y b y accident or an occupational disease which occurred on or by (Date) because ( Reason for Additional Medical Compensation ) 2. A dditional medical and/or other supporting documentation is / is not attached (optional). ( Place y our I.C. File # on each attachment. ) SIGNATURE OF EMPLOYEE DATE COMPLETED Name and address of employee's attorney, if any: EMPLOYEE: SEND THE ORIGINAL OF THIS FORM AND ANY SUPPORTING DOCUMENTATION TO THE INDUSTRIAL COMMISSION AS INSTRUCTED AT THE BOTTOM OF THIS FORM AND SEND A COPY TO THE EMPLOYER OR CARRIER / ADMINISTRATOR. SECTION B. TREATING PHYSICIAN'S STATEMENT ( OPTIONAL ) : This is to certif y 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. SIGNATURE OF TREATING PHYSICIAN PRINTED NAMEDATE A DDRESS CITY STATE ZIP American LegalNet, Inc. www.FormsWorkFlow.com