LAC 40:III.501. Request for Reimbursement; Form B

LOUISIANA SECOND INJURY BOARD REQUEST FOR REIMBURSEMENT—FORM B SIF CLAIM # EMPLOYEE: | DATE OF ACCIDENT: CARRIER/SELF-INS | CARRIER’S CLAIM#: EMPLOYER: | JCN #: AMOUNT WEEKLY | FROM-TO DATES THIS SUBMISSION | TOTAL WEEKS | TOTAL AMOUNT PAID TTD PTD SEB DEATH TOTAL INDEMNITY PAID THIS SUBMISSION | $ TOTAL MEDICAL BENEFITS PAID THIS SUBMISSION | $ TOTAL SETTLEMENT (INDEMNITY + MEDICAL) PAID THIS SUBMISSION | $ TOTAL WC BENEFITS PAID THIS SUBMISSION | $ THE FOLLOWING DOCUMENTATION MUST BE INCLUDED WITH THE FORM B SUBMISSION INDEMNITY REIMBURSEMENT REQUEST Electronic print-out of indemnity payments shall include: date of payment, payee, benefit dates (from/thru), amount paid, and check or ACH number MEDICAL REIMBURSEMENT REQUEST A. Electronic print-out of medical payments shall include: date of payment, payee, service dates (from/thru), amount paid, and check or ACH number B. Copies of all medical bills or EOBs ordered and numbered to correspond with electronic print-out (shall include patient info, provider info, date of service, CPT codes, ICD codes, and amount charged) SETTLEMENT REIMBURSEMENT REQUEST Signed petition, Judgement, Receipt and Release, Order from OWCA and a copy of the check or electronic print-out of payment which shall include: date of payment, payee, amount paid, and check or ACH number THIRD PARTY RECOVERY IS THERE ANY POTENTIAL TO RECOVER ALL OR A PORTION OF THE BENEFITS PAID TO THE INJURED EMPLOYEE FROM A THIRD PARTY? YES NO I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THIS REQUEST AND THE INFORMATION PROVIDED ON THIS FORM IS CORRECT AND ACCURATE TO THE BEST OF MY KNOWLEDGE: ________________________ ________________________ ________________ Signature Print Name Date Company: ________________________ Telephone: ________________________ SIB Form B 9/17