KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 2 VENDOR'S REQUEST FOR ADDITIONAL EXPENDITURES K-WC-R 99-8 (2-14) MAIL: Division of Workers Compensation Rehabilitation Unit 401 SW Topeka Blvd., Suite 2 Topeka, KS 66603-3105 FAX: (785) 296-0839 In accordance with the Kansas Workers Compensation Schedule of Medical Fees, rehabilitation providers are limited to $4,620 in vendor expenses (including a total of $1,617 per case for nonprofessional services, including travel and waiting charges) without prior written approval from the Division of Workers Compensation. If the vendor finds circumstances exist requiring expenditure over these established maximums, the assigned rehabilitation counselor must justify the additional expenses. Any expenditure over the established limits without prior Division approval may result in lost revenue to the vendor. Claimant: ________________________________________________ Social Security number: _____________________ Vendor: ________________________________________________________ Vendor number: ____________________ Employer: ________________________________________________________________________________________ Insurance carrier: __________________________________________________________________________________ Request for approval of nonprofessional services (including travel and waiting charges) over the maximum of $1,617. 1a. Total nonprofessional services to date: $ ________________ 1b. Additional amount requested: $ ________________ Request for approval for additional rehabilitation cost over $4,620 (includes all charges for nonprofessional services) 2a. Total vendor cost to date: $ _________________ (includes all nonprofessional service charges) 2b. Additional amount requested: $ ________________ (includes 1b or any additional nonprofessional service charges) 2c. Total projected cost to plan completion: $ _________________ (includes all nonprofessional service charges) Justification for additional expenditure (cont'd on page 2 ­ use additional pages as needed): Provide a complete breakdown of anticipated costs and thoroughly explain need for proposed expenditures. DIVISION OF WORKERS COMPENSATION ­ REHABILITATION UNIT 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000, ext. 2152 · Fax: (785) 296-0839 American LegalNet, Inc. www.FormsWorkFlow.com Kansas Department of Labor K-WC-R 99-8 ( ) Vendor's Request for Additional Expenditures Justification for additional expenditure (cont'd): Page 2 of 2 Rehabilitation counselor signature: _______________________________________________ Date: ________________ QRP number: ______________ cc: For Division of Workers Compensation Use Only Reviewer: _________________________________________________________________________ Date: __________________ Approved Division comments: Disapproved See comments cc: DIVISION OF WORKERS COMPENSATION ­ REHABILITATION UNIT 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000, ext. 2152 · Fax: (785) 296-0839 American LegalNet, Inc. www.FormsWorkFlow.com