Disputed Claim For Medical Treatment 1009 1009form

User Manual: 1009

Open the PDF directly: View PDF PDF.
Page Count: 2

1
E-Mail to: mgd1009@lwc.la.gov 1. Last four digit of Social Security No.
Fax to: OWCA – Medical Services 2. Date of Injury/Illness - -
ATTN: Medical Director 3. Parts of Body Injured
(225) 342-9836
Mail to: Medical Services 4. Date of Birth - -
P.O. Box 94040 5. Date of This Request - -
Baton Rouge, LA 70804 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 EMPLOYEE’S ATTORNEY (if any)
8.
Name
Street or Box
City
9.
Name
Street or Box
City
State Zip State Zip
Phone ( ) Phone ( )
Fax ( )
EMPLOYER INSURER/ADMINISTRATOR
(circle one)
10.
Name
Street or Box
City _
11.
Name
Street or Box
City
State Zip State Zip
Phone ( ) _ Phone ( )
Fax ( ) Fax ( )
HEALTH CARE PROVIDER EMPLOYER/INSURER ATTORNEY
12.
Name
Street or Box
City_
13.
Name
Street or Box
City
State Zip State Zip
Phone ( ) _ Phone ( )
Fax ( ) Fax ( )
LWC-WC 1009-Rev 12/2014
2
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/self-
insured 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

Navigation menu