Free State of New Jersey - New Jersey

State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, NJ 08625-0381 WC-381 (3-09)
SOCIAL SECURITY NUMBER:

MEDICAL PROVIDER APPLICATION FOR PAYMENT OR REIMBURSEMENT OF MEDICAL PAYMENT

CASE NO'S.: _____________________________ VICINAGE: _____________________________ For Office Use Only

NAME:

ATTORNEY FOR APPLICANT

FEDERAL EMPLOYER IDENTIFICATION NUMBER:

INJURED WORKER

NAME:

ADDRESS:

ADDRESS:

TELEPHONE NUMBER (AREA CODE):

vs
FEDERAL EMPLOYER IDENTIFICATION NUMBER:

APPLICANT

ADDRESS:

INSURANCE CARRIER

NAME:

NAME ADDRESS:

SELF-INSURED

NOT-COVERED

CLAIM NUMBER:

NAME:

EMPLOYER

ADDRESS:

Note: Corporations must be represented by counsel in Workers' Compensation Proceedings
The employee has has not filed a Workers' Compensation Claim Petition related to this injury. Claim Petition Number :

TO THE DIVISION OF WORKERS' COMPENSATION Applicant, alleging that the Employee sustained an injury by an accident arising out of and in the course of his / her employment with Respondent, compensable under R.S. 34:15-7 et seq., supplements and amendments, respectfully states: Date of Accident (If Known): Occupational Exposure Dates of Exposure: History of Accident or Illness: Date of Last Treatment :

Occupation: Sex: Date of Birth:

Date Stopped Work: Date Injury Reported to Employer and to Whom:

Date Returned to Work:

Diagnosis:

Date(s) of Treatment

Date Billed

Amount Billed

Amount Paid

What other facts are there that you believe important?

The Applicant therefore requests that the Division of Workers' Compensation determine the amount of payment due from said Respondent, under Revised Statutes of New Jersey, Title 34, Chapter 15, and the acts supplemental thereto and amendatory thereof, and that your Applicant may be awarded costs in this proceeding, and such other or further relief as may be proper.

Applicant

STATE OF NEW JERSEY COUNTY OF _________________ Subscribed and sworn or affirmed to before me this ________ day of ______________ , ________

_____________________________

This Application has been presented by the service provider to the Division of Workers' Compensation for hearing and determination. Unless an Answer is filed within 30 days of the date of service of the Applicant upon you, with the assignment clerk at the vicinage to which the claim is assigned as indicated on the reverse side, and a copy served upon the attorney, THE APPLICANT WILL PROCEED WITH PROOF OF CLAIM ACCORDING TO LAW AND MAY OBTAIN JUDGMENT AGAINST YOU. The Privacy Act, 5 U.S.C. §552a, the Social Security Act, 42 U.S.C. §405, and N.J.S.A. 34:15-1 et seq. authorize the Division of Workers' Compensation to request that the Applicant supply the Division with the employee's Social Security number for record keeping purposes and cross-matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any other proper public purpose.

DIVISION OF WORKERS' COMPENSATION