Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines
Subchapter B - Shoulder Injury Medical Treatment Guidelines
Section I-2328 - LWC-WC 1009. Disputed Claim for Medical Treatment
Current through Register Vol. 50, No. 9, September 20, 2024
E-Mail to: medicalservices@LWC.la.gov
Fax to: OWCA - Medical Services 1. Social Security No. __-__-__
ATTN: Medical Director 2. Date of Injury/Illness __-__-__
(225) 342-6556 3. Parts of Body Injury_________
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
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 issues 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
Claimant files this dispute with the Office of Workers' Compensation Medical Services Director. 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.
___ Employee ____ 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 director:
| EMPLOYEE | EMPLOYEE'S ATTORNEY |
| 8. Name ___________________ | 9. Name __________________ |
| Street or Box _______________ | Street or Box ______________ |
| City ______________________ | City _____________________ |
| State __________ Zip _______ | State ________ Zip _________ |
| Phone (____) ______________ | Phone (____) ______________ |
| Fax (____) ______________ |
| EMPLOYER | INSURER/ADMINISTRATOR |
| (circle one) | |
| 10. Name __________________ | 11. Name _________________ |
| Street or Box _______________ | Street or Box ______________ |
| City ______________________ | City _____________________ |
| State __________ Zip _______ | State ________ Zip _________ |
| Phone (____) ______________ | Phone (____) ______________ |
| Fax (____) ______________ | Fax (____) ______________ |
TREATING/REQUESTING
PHYSICIAN
Street or Box _______________
City ______________________
State __________ Zip _______
Phone (____) ______________
Fax (____) ______________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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 to their designated fax or email address.
The information given above is true and correct to the best of my knowledge and belief.
___________________________________ __________________
SIGNATURE OF REQUESTING PARTY DATE
___________________________________
Printed Name of Requesting Party
LWC-WC 1009
11/2010
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
