Application For Adjustment Of Claim For Provider Fee {18487}

Reset Form APPLICATION FOR ADJUSTMENT OF CLAIM FOR PROVIDER FEE State Form 18487 (R7 / 1-15) Approved by State Board of Accounts, 2015 WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204-2753 Telephone: (317) 232-3808 FOR STATE USE ONLY INSTRUCTIONS: 1. The application must file an original and two (2) copies of this application for it to be processed. 2. Mail to the Worker's Compensation Board at the above address. 3. For detailed instructions, go to www.in.gov/wcb/files/Provider_Memo.pdf. PLAINTIFF vs DEFENDANT Application number Name of plaintiff (provider) Address (number and street) City, state, and ZIP code Telephone number National Provider Identification number (NPI) Name of defendant (employer) Address (number and street) City, state, and ZIP code Telephone number Federal identification number Insurance claim number ( ) Name of attorney (must complete) Address (number and street) City, state, and ZIP code Telephone number E-mail address ( ) vs Name of insurance carrier Address (number and street) City, state, and ZIP code Name of adjuster Telephone number ( ) Attorney number E-mail address ( Must check one: Total Billing (no payment received) Balance Billing (partial payment received) Single Bundled For Balance Billing (A $60.00 filing fee must accompany the application.): Check number: ) Billing review company Name of reviewer Telephone number E-mail address ( ) THE PLAINTIFF RESPECTFULLY REPRESENTS TO THE BOARD AS FOLLOWS: That the defendants, as employer and employer's compensation insurance carrier, owe and are indebted to the plaintiff on account in the sum of provider's fee and supplies in the treatment of the injuries of Name of patient dollars for incurred as a result of an injury / illness arising out of and in the course of the employment with the defendant employer, on the day of , 20 , in the county of . The patient's date of birth is (month, day, year): The patient's address is (number and street, city, state, and ZIP code): Latest date of service (month, day, year): That said services were rendered as follows (check all that apply): In an emergency The employee was in need of timely services provided The employer failed to provide such service Employer or insurance carrier approved such services Provider first requested payment for said services on (month, day, year): The applicant certifies that required diligence has been accomplished and that the initial written response from the employer / representative was received on (month, day, year): Additional date(s) demands made (month, day, year): Date(s) of follow-up (month, day, year): Type of second request: Oral E-mail Written Date(s) (month, day, year): . Wheretofore the plaintiff prays to the Board to find against the defendant on said account the sum of $ Signature of plaintiff Date signed (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com