Notice That You May Be Responsible For Medical Costs {A-9}

A-9 - NOTICE THAT YOU MAYBE RESPONSIBLE FOR MEDICAL COSTS IN THE EVENT OF FAILURE TO PROSECUTE, OR IF COMPENSATION CLAIM IS DISALLOWED, OR IF AGREEMENT PURSUANT TO WCL §32 IS APPROVED. This form is a notice given to a claimant in a workers' compensation case, informing them that they may be responsible for medical costs under specific circumstances. It explains that if the claim is not pursued, the illness or condition is deemed non-compensable, or an agreement is reached waiving medical benefits, the healthcare provider may bill the claimant directly for services rendered. The form includes relevant case and contact information, requires the claimant's signature to acknowledge their understanding, and provides instructions to both the claimant and healthcare provider regarding their obligations and the billing process. www.FormsWorkflow.com