E-Mail to: mgd1009@lwc.la.gov Fax to: OWCA ­ Medical Services ATTN: Medical Director (225) 342-9836 Mail to: Medical Services P.O. Box 94040 Baton Rouge, LA 70804 1. Last four digit of Social Security No. 2. Date of Injury/Illness 3. Parts of Body Injured 4. Date of Birth 5. Date of This Request 6. Claim Number - DISPUTED CLAIM FOR MEDICAL TREATMENT (1009) NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS THERE ARE MEDICAL SERVICES IN DISPUTE AS PER R.S. 23:1203.1 J AND THE FOLLOWING HAS OCCURRED: A. The insurer has issued a denial. B. The insurer has issued an approval with modification. C. The insurer's failure to act has resulted in a deemed denial. D. The aggrieved party is seeking a variance from the medical treatment schedule DISPUTES RELATING TO COMPENSABILITY AND/OR CAUSATION ARE NOT ADDRESSED BY THE MEDICAL DIRECTOR. GENERAL INFORMATION An aggrieved party files this dispute with the Office of Workers' Compensation ­ Medical Services Director by mail, email or fax. This office must be notified immediately in writing of changes in address. An employee may be represented by an attorney, but it is not required. 7. This request is submitted by: ___ Employee/Employee Attorney ___ Health Care Provider ___ Other The completed LWC-WC-1009 must be submitted to OWCA within 15 calendar days of the 1010 denial, 1010 approval w/modification or 1010 deemed denial. The following records/documents MUST be attached to this request. Failure to do so may result in the rejection of the request by the OWCA Director: A. A copy of the LWC-WC-1010. B. All of the information previously submitted to the carrier/self-insured employer. C. Include scientific medical evidence when seeking a variance. D. If applicable, a copy of the denial letter issued by the insurance carrier. EMPLOYEE 8. Name Street or Box City State Zip Phone ( ) EMPLOYEE'S ATTORNEY (if any) 9. Name Street or Box City State Zip Phone ( ) Fax ( ) INSURER/ADMINISTRATOR (circle one) 11. Name Street or Box City State Phone ( ) Fax ( ) EMPLOYER 10. Name Street or Box City _ State Phone ( ) Fax ( ) Zip _ Zip HEALTH CARE PROVIDER 12. Name Street or Box City_ State Phone ( ) Fax ( ) LWC-WC 1009-Rev 12/2014 EMPLOYER/INSURER ATTORNEY 13. Name Street or Box City State Phone ( ) Fax ( ) Zip _ Zip 1 American LegalNet, Inc. www.FormsWorkFlow.com 12. PLEASE PROVIDE A SUMMARY OF THE DETAILS REGARDING THE ISSUE AT DISPUTE: You may attach a letter or petition with additional information with this disputed claim. By signing below, you are certifying that this form along with all supporting documentation has been sent to the carrier/selfinsured employer this date by e-mail or fax. The information given above is true and correct to the best of my knowledge and belief. SIGNATURE OF REQUESTING PARTY (Required) DATE Printed Named of Requesting Party LWC-WC 1009-Rev 12/2014 2 American LegalNet, Inc. www.FormsWorkFlow.com