Free Form 114 - Kentucky

Form 114

KENTUCKY DEPARTMENT OF WORKERS CLAIMS Frankfort, Kentucky 40601

REQUEST FOR PAYMENT FOR SERVICES OR REIMBURSEMENT FOR COMPENSABLE EXPENSES
TO BE FILED WITH THE RESPONSIBLE EMPLOYER OR ITS PAYMENT OBLIGOR Name, address and Workers Compensation claim number of Employee for whom services were provided or expenses incurred: ____________________________________________________________________________________________ ____________________________________________________________________________________________ â ã Specific type and dates of service(s) provided:
Date(s) Type of Service(s)

ä Name and address of physician who ordered services: (include written authorization if available) ____________________________________________________________________________________________ å Reasonable value of services, including method of computation: $_______________: _____________ ____________________________________________________________________________________________ æ Other expenses incurred for cure or relief of a work injury or occupational disease(s):
Description of Expense(s) $ Amount If mileage, no. of miles

Date

-------

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Total

$:

Miles:

Please attach receipts for all purchased items. Certification: I hereby certify that the above services were performed or expenses were incurred for the cure or relief of a work injury or occupational disease sustained by the above employee. Witness: ___________________________ Date: _______________________________ _________________________________________ Address: __________________________________________ Phone no: _________________________________________ NOTICE:
Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
(Name of Person requesting payment)