LOUISIANA WORKFORCE COMMISSION OFFICE OF WORKERS' COMPENSATION ADMINISTRATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9094 (800) 201-2494 SPECIAL REIMBURSEMENT CONSIDERATION APPEAL INSTRUCTIONS: Please provide the following information and return Parts 1 and 2 intact with the required medical records to the address shown below. Send Part 3 to the Workers' Compensation insurance carrier. Retain the last copy for your files. It should be understood that an appeal is not a guarantee of additional reimbursement. DATE WORKERS' COMPENSATION CARRIER NAME AND ADDRESS HOSPITAL INFORMATION HOSPITAL NAME ADDRESS CONTACT PERSON TITLE CITY, STATE, ZIP TELEPHONE EXT PATIENT INFORMATION PATIENT NAME EMPLOYER NAME AND ADDRESS PATIENT ADDRESS DIAGNOSIS AND SURGICAL PROCEDURES WAS ADMISSION PRE-CERTIFIED? YES NO CITY, STATE, ZIP SOCIAL SECURITY NUMBER DATES OF SERVICE IF NO, HAS OFFICE OF WORKERS' COMPENSATION BEEN NOTIFIED OF THE ADMISSION? YES NO MEDICAL INFORMATION The following information must be submitted with and appeal for special reimbursement consideration. · · Entire medical record Itemization of charges · All supporting information which could substantiate percentage of charge reimbursement. STATE OFFICE OF WORKERS' COMPENSATION USE ONLY SPECIAL CASE CONSIDERATION NAME REASON TITLE APPROVED DENIED REIMBURSEMENT RATE SEND THIS FORM TO : Louisiana Workforce Commission Office of Workers' Compensation Administration Medical Services Section Post Office Box 94040 Baton Rouge, LA 70804-9040 LWC-WC 3000 American LegalNet, Inc. www.FormsWorkflow.com