LWC FORM 1010 - REQUEST OF AUTHORIZATION/CARRIER OR SELF INSURED EMPLOYER RESPONSE PLEASE PRINT OR TYPE P A T I E N T C A R R I E R Last Name: SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care Provider First: Middle: Street Address, City, State, Zip: Date of Birth: Phone Number: Date of Injury: Phone Number: Claim Number (if known): Phone Number: Fax Number: Last 4 Digits of Social Security Number: Employers Name: Name: Street Address, City, State Zip: Street Address, City, State, Zip: Adjuster: Email Address: SECTION 2. REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider Requesting Health Care Provider: Fax Number: Phone Number: P R O V I D E R Street Address, City, State Zip: Diagnosis: Requested Treatment or Testing (Attach Supplement If Needed): Reason for Treatment or Testing (Attach Supplement If Needed): Email: CPT/DRG Code: ICD/DSM Code: INFORMATION REQUIRED BY RULE TO BE INCLUDED WITH REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider (Following is the required minimum information for Request of Authorization (LAC 40:2715 (C)) History provided to the level of condition and as provided by Medical Treatment Schedule Physical Findings/Clinical Tests P R O V I D E R Documented functional improvements from prior treatment Test/imaging results Treatment Plan including services being requested along with the frequency and duration I hereby certify that this completed form and above required information was Signature of Health Care Provider: Faxed Emailed to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) Printed Name: SECTION 3. RESPONSE OF CARRIER/SELF INSURED EMPLOYER FOR AUTHORIZATION (Check appropriate box below and return to requesting Health Care Provider, Claimant and Claimant Attorney as provided by rule) The requested Treatment or Testing is approved The requested Treatment or Testing is approved with modifications (Attach summary of reasons and explanation of any modifications) The requested Treatment or Testing is denied because Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons) The request, or a portion thereof, is not related to the on-the-job injury The claim is being denied as non-compensable Other (Attach brief explanation) C A R I hereby certify that this response of Carrier/Self Insured Employer for Authorization was R I E R Signature of Carrier/Self Insured Employer or Utilization Review Company: Faxed to the Health Care Provider (and to the Attorney of Claimant if one exists, if denied or approved with modification) on this the Emailed _____ day of ______ , ______ (day) (month) (year) Printed Name: The prior denied or approved with modification request is now approved Faxed I hereby certify that this response of Carrier/Self Insured Employer for Authorization was y y p py to the Health Care Provider and Attorney of Claimant if one exists on this the Emailed Signature of Carrier/Self Insured Employer or Utilization Review Company: _____ day of ______ , ______ (day) (month) (year) Printed Name: American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4. FIRST REQUEST (Form 1010A is required to be filled out by Carrier/Self Insured Employer and Health Care Provider) The requested Treatment or Testing is delayed because minimum C A R I hereby certify that this First Request and accompanying Form 1010A was R I E Signature of Carrier/Self Insured Employer or Utilization Review Company: R P R I hereby certify that a response to the First Request and O accompanying Form 1010A was V I D Signature of Health Care Provider: E R information required by rule was not provided Faxed Emailed to the Health Care Provider on this the _____ day of ______ , ______ (day) (month) (year) Faxed Emailed to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) Printed Name: SECTION 5. SUSPENSION OF PRIOR AUTHORIZATION DUE TO LACK OF INFORMATION Suspension of Prior Authorization Process due to Lack of Information C A R R I E R The requested Treatment or Testing is delayed due to a Suspension of Prior Authorization Due to Lack of Information Faxed I hereby certify that this Suspension of Prior Authorization was Emailed Signature of Carrier/Self Insured Employer or Utilization Review Company: to the Health Care Provider on this the _____ day of ______ , ______ (day) Printed Name: (month) (year) Appeal of Suspension to Medical Services Section by Health Care Provider P R O V I D E R I hereby certify that this form and all information previously submitted to Carrier/Self Insured Employer was faxed to OWCA Medical Services (Fax Number: 225-342-9836 this _______ day of ______, _________. I hereby certify that this Appeal of Suspension of Prior Authorization was Signature of Health Care Provider: Faxed Emailed to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) Printed Name: SECTION 6. DETERMINATION OF MEDICAL SERVICES SECTION The required information of LAC40:2715(C) was not provided The required information of LAC40:2715(C) was provided O W C A I hereby certify that a written determination was Signature: Faxed Emailed to the Health Care Provider & Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) (month) (year) Printed Name: SECTION 7. HEALTH CARE PROVIDER RESPONSE TO MEDICAL SERVICES DETERMINATION P R O I hereby certify that additional information, pursuant to Medical Services Section, was V I D E Signature of Health Care Provider: R the determination of Faxed Emailed to the Carrier/Self Insured Employer on this the _____ day of ______ , ______ (day) Printed Name: (month) (year) American LegalNet, Inc. www.FormsWorkFlow.com