Disputed Claim For Medical Treatment 1009 1009form

User Manual: 1009

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E-Mail to: mgd1009@lwc.la.gov
Fax to: OWCA – Medical Services
ATTN: Medical Director
(225) 342-9836
Mail to: Medical Services
P.O. Box 94040
Baton Rouge, LA 70804

1. Last four digit of Social Security No.
2. Date of Injury/Illness
3. Parts of Body Injured
4. Date of Birth
5. Date of This Request
6. Claim Number

-

-

DISPUTED CLAIM FOR MEDICAL TREATMENT (1009)
NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS THERE ARE MEDICAL SERVICES IN DISPUTE AS PER
R.S. 23:1203.1 J AND THE FOLLOWING HAS OCCURRED:
A. The insurer has issued a denial.
B. The insurer has issued an approval with modification.
C. The insurer’s failure to act has resulted in a deemed denial.
D. The aggrieved party is seeking a variance from the medical treatment schedule
DISPUTES RELATING TO COMPENSABILITY AND/OR CAUSATION ARE NOT ADDRESSED BY THE MEDICAL
DIRECTOR.
GENERAL INFORMATION
An aggrieved party files this dispute with the Office of Workers’ Compensation – Medical Services Director by mail, email or fax. This
office must be notified immediately in writing of changes in address. An employee may be represented by an attorney, but it is not
required.
7. This request is submitted by:
___ Employee/Employee Attorney

___ Health Care Provider

___ Other

The completed LWC-WC-1009 must be submitted to OWCA within 15 calendar days of the 1010 denial, 1010
approval w/modification or 1010 deemed denial. The following records/documents MUST be attached to this
request. Failure to do so may result in the rejection of the request by the OWCA Director:
A. A copy of the LWC-WC-1010.
B. All of the information previously submitted to the carrier/self-insured employer.
C. Include scientific medical evidence when seeking a variance.
D. If applicable, a copy of the denial letter issued by the insurance carrier.
EMPLOYEE
8. Name
Street or Box
City
State
Zip
Phone (
)

EMPLOYEE’S ATTORNEY (if any)
9. Name
Street or Box
City
State
Zip
Phone (
)
Fax (
)

EMPLOYER
10. Name
Street or Box
City _
State
Phone (
)
Fax (
)

INSURER/ADMINISTRATOR
(circle one)

Zip
_

HEALTH CARE PROVIDER
12. Name
Street or Box
City_
State
Phone (
)
Fax (
)

11. Name
Street or Box
City
State
Phone (
)
Fax (
)

Zip

EMPLOYER/INSURER ATTORNEY

Zip
_

13. Name
Street or Box
City
State
Phone (
)
Fax (
)

Zip

LWC-WC 1009-Rev 12/2014

1

12.

PLEASE PROVIDE A SUMMARY OF THE DETAILS REGARDING THE ISSUE AT DISPUTE:

You may attach a letter or petition with additional information with this disputed claim.
By signing below, you are certifying that this form along with all supporting documentation has been sent to the carrier/selfinsured employer this date by e-mail or fax.
The information given above is true and correct to the best of my knowledge and belief.

SIGNATURE OF REQUESTING PARTY (Required)

DATE

Printed Named of Requesting Party

LWC-WC 1009-Rev 12/2014

2
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Linearized                      : Yes
Author                          : OWC
Company                         : 
Created                         : D:20141203
Create Date                     : 2014:12:04 13:29:52-06:00
Keywords                        : OWC 1009, form 1009, disputed claim
Last Saved                      : D:20141203
Modify Date                     : 2015:03:14 08:55:07-05:00
Source Modified                 : D:20141204192812
Subject                         : Form to be filed with the Workers' Compensation Medical Services Director when there is a Disputed Claim for Medical Treatment.
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Format                          : application/pdf
Title                           : Disputed Claim for Medical Treatment
Description                     : Form to be filed with the Workers' Compensation Medical Services Director when there is a Disputed Claim for Medical Treatment.
Creator                         : OWC
Producer                        : Adobe PDF Library 11.0
State                           : 1
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Headline                        : Form to be filed with the Workers' Compensation Medical Services Director when there is a Disputed Claim for Medical Treatment.
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