Request For Payment For Services Or Reimbursement For Compensable Expenses
Request For Payment For Services Or Reimbursement For Compensable Expenses Form. This is a Kentucky form and can be use in Workers Comp.
Tags: Request For Payment For Services Or Reimbursement For Compensable Expenses, 114, Kentucky Workers Comp,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. KENTUCKY DEPARTMENT OF WORKERS CLAIMS Frankfort, Kentucky 40601 Calendar No. : Form 114 : REQUEST FOR PAYMENT Plaintiff(s) FOR SERVICES OR JUDICIAL SUBPOENA REIMBURSEMENT FOR -against- COMPENSABLE EXPENSES : TO BE FILED WITH THE RESPONSIBLE EMPLOYER OR ITS PAYMENT OBLIGOR : Name, address and Workers Compensation claim number of Employee for whom services were provided or expenses incurred: : ____________________________________________________________________________________________ ____________________________________________________________________________________________ Defendant(s) : â ...................................................... ã Specific type and dates of service(s) provided: Date(s) Type of Service(s) THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable address of physician who ordered services: (include written authorization if available) at the Court ä Name and located at County of ____________________________________________________________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed orå Reasonable value of services, including method of computation: on the part of the _____________ adjourned date, to testify and give evidence as a witness in this action $_______________: ____________________________________________________________________________________________ æ Other expenses incurred for cure or relief of a work injury or occupational disease(s): Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Description this subpoena theDate on whose behalf of Expense(s) was issued for a maximum $ Amount $50If mileage, no. of miles party penalty of and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, ------- , one of the Justices of the day of , 20 (Attorney - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Total $: must sign above and type name below) Miles: Please attach receipts for all purchased items. Certification: Attorney(s) for I hereby certify that the above services were performed or expenses were incurred for the cure or relief of a work injury or occupational disease sustained by the above employee. Witness: ___________________________ Date: _______________________________ _________________________________________ Office and P.O. Address (Name of Person requesting payment) Address: __________________________________________ Phone no: _________________________________________ Telephone No.: NOTICE: Facsimile No.: Any person who knowingly and with intent to defraud any insurance company or other person files a E-Mail Address: statement or claim containing any materially false information or conceals, for the purpose of misleading, Mobile Tel. No.: information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. American LegalNet, Inc. www.USCourtForms.com