Send original to Workers' Compensation Court and 1 copy to Claimant/Claimant's Counsel and 1 copy to Health/Rehabilitation Provider In re claim of:
Full Name of Injured Employee (Claimant) Claimant's Social Security Number Name of Employer (Respondent)
WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLA.CITY, OKLAHOMA 73105-4918
THIS SPACE FOR COURT USE ONLY
Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured Name of Claiming Provider Provider's Address (Please Type or Print) Address of Employee (Claimant): Number & Street
RESPONSE TO REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES FILE NO. Date of Injury (Must be filled out)
Address of Employee (Respondent):
Number & Street
NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or in-state toll free (800) 522-8210.
2. Grounds for the refusal of payment?
________ ________ 1. Has payment been refused? ________ ________ ________ ________ ________ ________ ________ ________
a. necessity of treatment rendered. b. unauthorized physician. c. denial of compensability of the claimant's accidental injury or occupational disease. d. other, including affirmative defenses (explain)____________________________________________________________________
________ ________ 3. Was provider notified of refusal of payment within 60 days? ________ ________ 4. Has an order from the Workers' Compensation Court been issued regarding the compensability of the claimant's request for
compensation? Date of order ________________________________________________________________________________
________ ________ 5. Has the claimant's request for benefits been resolved by Settlement or Agreement of the parties?
Date of Settlement or Agreement _____________________________________________________________________________
________ ________ 6. Has claimant been provided Temporary Total Disability benefits? Date TTD benefits provided: _______________to______________
7. List all other medical providers in this claim which are in dispute: Medical/Rehabilitation Provider______________________________________________ __________________________________________________________________________________________________________________________ 8. List the names of all witnesses who may be called by respondent at trial: ________________________________________________________________ __________________________________________________________________________________________________________________________ 9. List all exhibits to be introduced at trial: ___________________________________________________________________________________________
If the dispute involves the length or necessity of treatment rendered, or relates to complex medical treatment rendered beyond the limitation of the Schedule of Medical and Hospital Fees, a narrative medical report opposing the treatment provided and/or the charges submitted must be sent to the health/rehabilitation provider. Do NOT attach a copy of the medical report when filing the Form 10M with the Workers' Compensation Court.
I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.
Signed this________________day of______________________,___________.
I HEREBY CERTIFY THAT A COPY OF THIS FORM AND ALL RELEVANT MEDICAL REPORTS HAVE BEEN SENT TO: Claimant Health/Rehabilitation Provider Signature of Responding Party Address (Number & Street) City Zip Code State Zip Code
Address (Number & Street) City State
Telephone # of Responding Party Print or type name of Attorney OBA #