State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, NJ 08625-0381 WC-381 r. 8/26/2015 MEDICAL PROVIDER APPLICATION FOR PAYMENT OR REIMBURSEMENT OF MEDICAL PAYMENT CASE NO'S.: ___________________________ VICINAGE: ___________________________ NEW FILING * Required if Applicant is a Corporation * **please enter above only if filing an Amended Claim** AMENDED FILING TAX IDENTIFICATION NUMBER: NAME: ADDRESS: TAX IDENTIFICATION NUMBER: NAME: ADDRESS: TELEPHONE NUMBER: ATTORNEY FOR APPLICANT APPLICANT TELEPHONE NUMBER : FAX NUMBER: vs NAME: IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE BELOW: ADDRESS: INSURANCE CARRIER NAME : ADDRESS: EMPLOYER CARRIER CLAIM NUMBER: INDICATE THE STATUS OF THE EMPLOYER: I IF UNINSURED, INDIVIDUAL CORPORATE OFFICERS ARE ALSO NAMED AS RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS. SOCIAL SECURITY NUMBER: NSURED UNI NSURED SELF-I NSURED (PRIVATE) SELF-INSURED (GOVT. AGENCY.) INJURED WORKER NAME: ADDRESS: SSN Not Available Note: Corporations must be represented by counsel in Workers' Compensation Proceedings The injured worker has Petition related to this injury. Claim Petition #: has not filed a Workers' Compensation Claim DATE OF BIRTH: SEX: TO THE DIVISION OF WORKERS' COMPENSATION Applicant, alleging that the Employee sustained an injury by an accident arising out of and in the course of his / her employment with Respondent, compensable under R.S. 34:15-7 et seq., supplements and amendments, respectfully states: Date of Accident or Injury(required): Occupation: Date of Last Treatment: Diagnosis: Occupational Exposure History of Accident or Illness: Date(s) of Treatment: 1. 2. 3. 4. See attached for additional treatment Date Billed: Amount Billed: Amount Paid: American LegalNet, Inc. www.FormsWorkFlow.com What other facts are there that you believe important? Summary of Changes (Complete only if filing an Amended pleading): The Applicant therefore requests that the Division of Workers' Compensation determine the amount of payment due from said Respondent, under Revised Statutes of New Jersey, Title 34, Chapter 15, and the acts supplemental thereto and amendatory thereof, and that your Applicant may be awarded costs in this proceeding, and such other or further relief as may be proper. Applicant STATE OF NEW JERSEY COUNTY OF ________________________ Subscribed and sworn or affirmed to before me this _______ day of __________________ , 20_____ ____________________________________________ This Application has been presented by the service provider to the Division of Workers' Compensation for hearing and determination. Unless an Answer is filed within 30 days of the date of service of the Applicant upon you, with the assignment clerk at the vicinage to which the claim is assigned as indicated on the reverse side, and a copy served upon the attorney, THE APPLICANT WILL PROCEED WITH PROOF OF CLAIM ACCORDING TO LAW AND MAY OBTAIN JUDGMENT AGAINST YOU. The Privacy Act, 5 U.S.C. §552a, the Social Security Act, 42 U.S.C. §405, and N.J.S.A. 34:15-1 et seq. authorize the Division of Workers' Compensation to request that the Applicant supply the Division with the employee's Social Security number for record keeping purposes and cross-matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any other proper public purpose. American LegalNet, Inc. www.FormsWorkFlow.com