LAC 40:I.2328. LWC-WC 1009. Disputed Claim for Medical Treatment

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/tacit denial; or 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. 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/tacit denial. A deemed/tacit denial is when a carrier/self-insured employer fails to return the LWC-WC-1010 form within five business days of submission of the form to the carrier/self-insured employer. 7. This request is submitted by: Employee/Employee’s Attorney Health Care Provider Other: _____________________ 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 Assistant Secretary: A. Copies of all relevant information must be included with this request as per LAC 40:I.2715 (J) including a copy of the LWC-WC-1010 and all of the information previously submitted to the carrier/self-insured employer. B. If applicable, a copy of the denial letter issued by the insurance carrier or utilization review company. C. Include scientific medical evidence when seeking a variance. EMPLOYEE EMPLOYEE’S ATTORNEY (if any) 8. Name ____________________________ 9. Name ______________________________ Street or Box ______________________ Street or Box _________________________ City _____________________________ City ________________________________ State ____________________ Zip _______ State ___________________ Zip _________ Phone (_____) _______________________ Phone (_____) ________________________ Fax (_____) ________________________ Email ________________________________ Employer Insurer/Administrator (circle one) 10. Name _____________________________ 11. Name ______________________________ Street or Box ________________________ Street or Box ________________________ City _______________________________ City _______________________________ State __________________ Zip ________ State ___________________ Zip ________ Phone (_______) _____________________ Phone (_____) _______________________ Fax (_______) _______________________ Email ______________________________ Treating/Requesting Physician EMPLOYER/INSURER ATTORNEY 12. Name ______________________________ 13. Name _____________________________ Street or Box _________________________ Street or Box ________________________ City ________________________________ City _______________________________ State ____________________ Zip ________ State ___________________ Zip ________ Phone (_____) ________________________ Phone (_____) _______________________ Fax (_____) ________________________ Fax (_____) _______________________ Email _______________________________ Email ______________________________ 14. PLEASE PROVIDE A SUMMARY OF THE DETAILS REGARDING THE ISSUE AT DISPUTE: (If requesting a variance, explain here) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 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 Name of Requesting Party