American LegalNet, Inc. www.FormsWorkFlow.com Form AR-MARKANSAS WORKERS222 COMPENSATION COMMISSION324 Spring Street, Little Rock, AR 72201Mail: P. O. Box 950, Little Rock, AR 72203-0950501-682-3930 / 1-800-622-4472MAuthority: Ark. CodeAnn. 247 11-9-528, 529AWCC Rule 8Revised: 1-1-2001MONTHLY REPORT ON MEDICAL - ONLY INJURY DATATO BE COMPLETED BY CARRIERS AND SELF-INSURED EMPLOYERS EACH MONTH ON CASES NOT OPENED BY FORM 1 OR FORM C.Report Period (Month, Year)Carrier or Self-Insured NameFEIN No.Claim Office/TPA Filing ReportMailing AddressCityStateZip Code MONTHLY MEDICAL-ONLY INJURY DATATotal No. of Medical-Only Injury Reports ReceivedTotal No. of Days LostTotal Medical ExpenseGive Total Number of Reported Injuries by Body Part (Must Equal Total No. of Injuries Reported Above)Head, Face and Neck: Eyes, Ears, Nose and Mouth: Hands, Arms and Fingers: Back and Hip: Chest and Lungs: Legs, Feet and Toes: Abdomen: Other or Multiple: CERTIFICATIONI certify that the foregoing is a complete and accurate report for the above referenced carrier or self-insured employer of all medical-only claimsreported and paid by that entity for the report period.SignaturePrinted or Typewritten NameTitleDateTelephone Number (including Area Code)(See Instructions on Back of This Sheet)MAmerican LegalNet, Inc. www.FormsWorkFlow.com Help with the Form M is available from the Research and Statistics Section. Generalinformation is available from the Support Services Division (1-800-622-4472 or 501-682-3930). AWCC Form M (Monthly Report on Medical-Only Injury Data)Instructions for Form M: Send Form M to the AWCC Research & Statistics Section after the close of each month and by the 15th day of the next month.Spell out the name of the carrier or self-insured; do not abbreviate.Count calendar days lost rather than just work days.All accidents/injuries resulting in disability of more than seven days, death cases, or those involving payment of weeklycompensation shall be reported to the Commission on Form 1. In the event cases reported as medical-only develop intocompensable cases, these previously-counted totals should be subtracted in subsequent Form M Monthly Reports.All accidents/injuries, other than death, resulting in disability of seven days or less, must be reported on this form. This reportis to be completed by all insurance carriers and self-insured employers providing workers222 compensation coverage in Arkansas.Companies/employers that have coverage with an insurance carrier are not required to complete this form.Report expenses each month. When medicals are carried over into another month, expenses should be included on future MForms, but the accident should only be counted once.Separate reports must be submitted for each separate carrier or self-insured FEIN number.Third-party administrators/service companies should NOT complete this form unless designated to do so by the carrier or self-insured. Reports with 223No Activity224 during the period must be completed and so indicated.NOTE: The Commission has the authority to levy a fine up to $500 per report per carrier or self-insured FEIN for failure tosubmit or late submi of this form. FAX reports are acceptable. The fax number is (501)682-. Ark. Code Ann. 24711-9-106(a): 223Any person or entity who willfully and knowingly makes any material false statementor representation, who willfully and knowingly omits or conceals any material information, or who willfully andknowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating orwrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers222compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of saidpurposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed andcollected under .... this section shall be paid and allocated in accordance with applicable law to the Death and PermanentTotal Disability Trust Fund administered by the Workers222 Compensation Commission.224