Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper) {C-251.1}

<document>STATE OF NEW YORKWORKERS' COMPENSATION BOARDCARRIER'S REQUEST FOR REIMBURSEMENT OF MEDICAL EXPENSES UNDER SEC. 15-8WCB CASE NO.CARRIER CASE NO.CARRIER ID NO. WSOC. SEC. NO.CARRIER'S ADDRESS CARRIER'S NAMECLAIMANT'S NAMEIn support of this request the following statements are submitted:MEDICAL EXPENSES:Paid for treatment rendered during period from To. (Receipted bills or photocopies must be attached to original copy.)TOTAL $S T A T E M E N TI hereby certify that this request for reimbursement made to the Chairman of the Workers' Compensation Board is true and correct; that no part thereof has been previously paid and the amount stated therein is due and owing.Signature: Date:Title: Telephone No.:DO NOT USE SPACE BELOWINSTRUCTIONS:1. Where possible, claim should be submittedTO: CHAIRMAN, WORKERS' COMPENSATION BOARD The Special Funds Conservation Committee approves reimbursement for the above claim totaling $.for 26 week periods. 2. Forward original and two copies to the local officeAgreed Date for Medical Reimbursementof the Special Funds Conservation Committee. 3. Retain one copy.ByDateC-251.1 (11-01)2002 © American LegalNet, Inc.</document>