Free 18487.FH11 - Indiana

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APPLICATION FOR ADJUSTMENT OF CLAIM FOR PROVIDER FEE
State Form 18487 (R5 / 4-09)

WORKERS COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204-2753

INSTRUCTIONS:

1. The applicant must file an original and four (4) copies of this application for it to be processed. 2. Mail to the Workers Compensation Board at the above address. PLAINTIFF vs DEFENDANT

FOR STATE USE ONLY
Application number

Name of plaintiff (provider) Address (number and street) City, state, and ZIP code Telephone number Federal identification number

Name of defendant (employer) Address (number and street) City, state, and ZIP code Telephone number Federal identification number Insurance claim number

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Name of attorney (must complete) Address (number and street) City, state, and ZIP code Telephone number E-mail address

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Name of insurance carrier Address (number and street) City, state, and ZIP code Name of adjuster Telephone number

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Attorney number

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E-mail address

Billing review company Name of reviewer Must check one

Total Billing (no payment received) Balance Billing (partial payment received)

Telephone number

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E-mail address

THE PLAINTIFF RESPECTFULLY REPRESENTS TO THE BOARD AS FOLLOWS:

That the defendants, as employer and employers compensation insurance carrier, owe and are indebted to the plaintiff on account in the sum of ___________________________________________________________________________________________ dollars for providers fee and supplies in the treatment of the injuries of ____________________________________________________________
Name of injured person

incurred as a result of an injury / illness arising out of and in the course of the employment with the defendant employer, on the ________ day of ______________________________, 20______, in the county of _________________________________. Latest date of service (month, day, year): ____________________________________ That said services were rendered as follows (check one): In an emergency The employer failed to provide such service The employee was in need of timely services provided Employer or insurance carrier approved such services Provider first requested payment for said services on (month, day, year): ____________________________________ Provider demands payment by (month, day, year): ____________________________________ Wheretofore the plaintiff prays to the Board to find against the defendant on said account the sum of $ __________________________.
Signature of plaintiff Date signed (month, day, year)