Medical Treatment Statement Supplies And Medications
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Medical Treatment Statement Supplies And Medications Form. This is a Wisconsin form and can be use in Workers Comp.
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Tags: Medical Treatment Statement Supplies And Medications, WKC-3, Wisconsin Workers Comp,
Complete this form before the prehearing conference (if one is scheduled) and updateit before the formal hearing. Bring this form to both the conference and hearing.NOTE: An itemized statement for each expense claimed must be attached to this form and provided to the Worker222s CompensationDivision and other parties to this case at least 15 days before the hearing, according to section 102.17(8) of the statutes.*Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay.Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].WC Claim NumberEmployee Name Employee Social Security Number*Employer Name Injury DateInsurance Company Name Have You Applied For Or Are You ReceivingSocial Security Benefits? Yes NoHave You Applied For Or Are You Covered Under Medicare? Yes No If Yes, Medicare Claim Number: Names of Providers of Treatment,Medication, or SuppliesTotalChargesAmount Paid ByApplicantAmount Paid By OtherInsurance Carriers(Give Carriers222 Names)UnpaidBalance TOTAL: WKC-3(R. 04/2019) Department of Workforce DevelopmentWorker222s Compensation Division201 E. Washington Ave., Rm. C100P.O. Box 7901Madison, WI 53707Litigated Fax: (608) 260-3053Telephone: (608) 266-1340https://dwd.wisconsin.gov/wc MEDICAL TREATMENT STATEMENTSUPPLIES AND MEDICATIONS American LegalNet, Inc. www.FormsWorkFlow.com
