Free Microsoft Word - Petition For An Order Concerning Payment For Medical Servi. - Rhode Island


File Size: 135.6 kB
Pages: 1
Date: October 16, 2008
File Format: PDF
State: Rhode Island
Category: Workers Compensation
Author: maveno
Word Count: 367 Words, 3,251 Characters
Page Size: 612 x 1008 pts
URL

http://www.courts.ri.gov/workers/forms/Interactive%20Petition%20For_An_Order_Concerning_Payment_For_Medical_Services.pdf

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W.C.C. # of pending petitions:

__________________________ __________________________

State of Rhode Island and Providence Plantations Providence, SC. Workers' Compensation Court
W.C.C. #
Health Care Provider:

________________________

Employee to whom services were furnished:

___________________________________
Health Care Provider-Petitioner

___________________________________
Patient Name

___________________________________
Address

___________________________________
Address

___________________________________ -V-

___________________________________ XXX-XX-__________________________
Social Security Number (last four digits only)

Employer:

Insurance Carrier:

___________________________________
Employer Name

___________________________________
Insurer Name

___________________________________
Address

___________________________________
Address

___________________________________
Agent for Service of Process (if a corporation or partnership):

___________________________________

___________________________________
Agent of Service Name

___________________________________
Address

___________________________________ Petition For An Order Concerning Payment For Medical Services
The petitioner requests an order for the payment of medical or related services, as defined in the Workers' Compensation Act, which were furnished by the petitioner to the above named injured employee, and in support of this petition states: 1. 2. The above named employer is liable for the payment of such medical and related services by reason of an agreement or decree concerning compensation. A copy of said agreement or decree establishing such liability is attached hereto. The services furnished were necessary in order to cure, rehabilitate or relieve said employee from the effect of an injury which was sustained on (Date of Injury) __________________or from the effect of an occupational disease which caused disablement on said date. The petitioner has complied with all requirements of the Workers' Compensation Act concerning notice, reports, bills, and permission for surgery, if applicable, pursuant to R.I.G.L. 28-33-5 through 28-33-10. An itemized bill and corresponding reports in triplicate, showing dates, C.P.T. codes, nature of services, charges, and credits for any payments received, is filed herewith, pursuant to R.I.G.L. 28-33-8 (f)(1). That twenty-one (21) days have passed since request for payment upon the employer or insurer or written notice to the employer or insurer of their failure to fulfill the obligation pursuant to R.I.G.L. 28-33-8.

3. 4. 5.

Name, Address, Phone Number and Bar Registration Number of Attorney for Petitioner

____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
Petitioner

____________________________________________
Date

File the original and three copies with the appropriate attachments with the Office of the Administrator of the Workers' Compensation Court, J. Joseph Garrahy Judicial Complex, One Dorrance Plaza, Providence, Rhode Island 02903-3973. Rev 02/08 Distribution: White: Court Yellow: Employee Pink: Employer Gold: Insurer