Free Form 18M - North Carolina


File Size: 27.6 kB
Pages: 1
File Format: PDF
State: North Carolina
Category: Workers Compensation
Author: Mcdowelr
Word Count: 333 Words, 2,249 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ic.nc.gov/ncic/pages/form18m.pdf

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Preview Form 18M
North Carolina Industrial Commission
IC File #

EMPLOYEE'S APPLICATION FOR ADDITIONAL MEDICAL COMPENSATION (G.S. 97-25.1)
(APPLICABLE TO INJURIES BY ACCIDENT OR OCCUPATIONAL DISEASES CONTRACTED ON OR AFTER 5 JULY 1994)
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Emp. Code # Carrier Code # Employer FEIN

.

(
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

)
Telephone Number City State Zip

(

) M F

( /

)
City State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

/

(

)

(

)

Date of Birth

Carrier's Telephone Number

SECTION A. TO BE COMPLETED BY EMPLOYEE:
1. The above-named employee claims additional medical compensation as a result of an injury by accident or an occupational disease which occurred on or by (Date) because
(Reason for Additional Medical Compensation)

2. Additional medical and/or other supporting documentation is / is not attached (optional). (Place your 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 TO THE INDUSTRIAL COMMISSION AT THE ADDRESS BELOW, AND A SIGNED EMPLOYER OR CARRIER/ADMINISTRATOR.

COPY TO THE

SECTION B. TREATING PHYSICIAN'S STATEMENT (OPTIONAL) :
This is to certify 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 ADDRESS PRINTED NAME CITY STATE DATE ZIP

MAIL TO:
FORM 18M 2/01 PAGE 1 OF 1

FORM 18M

NCIC EXECUTIVE SECRETARY 4333 MAIL SERVICE CENTER RALEIGH, NC 27699-4333 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/