Providers Petition For Payment Of Medical And Related Services
Providers Petition For Payment Of Medical And Related Services Form. This is a Maine form and can be use in Workers Compensation.
Tags: Providers Petition For Payment Of Medical And Related Services, WCB-190A, Maine Workers Compensation,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. PROVIDER S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES : JUDICIAL SUBPOENA Plaintiff(s) STATE OF MAINE -againstWORKERS COMPENSATION :BOARD 27 STATE HOUSE STATION : AUGUSTA, MAINE 04333-0027 : HEALTH CARE PROVIDER NAME: EMPLOYER Defendant(s) ) NAME: : ...................................................... ) STREET/P.O. BOX: ) CITY, STATE, ZIP: CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ ) THE PEOPLE OF THE STATE OF NEW YORK ) EMPLOYEE NAME: TO EMPLOYEE SOCIAL SECURITY NUMBER: _______________________ ) NAME: ) STREET/P.O. BOX: DATE OF INJURY: BOARD FILE NUMBER: ________________________________________ ) CITY, STATE, ZIP: GREETINGS: STREET/P.O. BOX: INSURANCE COMPANY (IF KNOWN) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , , the Honorable at the Court EMPLOYEE NAME MONTH DAY Y EAR located at County of experienced a work-related injury while of . in room , on the day working for , 20 , at o'clock in the noon, and at any recessed EMPLOYER NAME or adjourned date, to testify and give evidence as a witness in this action on the part of the 1. On 2. The charges for medical and related services in connection with this injury amount to: $________________________. ATTACH COPIES OF ALL BILLS Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of the failure to comply. WHEREFORE, your health care provider asks the Board to order payment of the attached work-related medical bills and services pursuant to 39-A M.R.S.A. Witness, Honorable Court in County, , one of the Justices of the day of ____________________________________________________ SIGNATURE OF HEALTH CARE REPRESENTATIVE , 20 DATED:____________________________________________________ MONTH DAY YEAR (Attorney must sign above and type name below) FILING INSTRUCTIONS 1. 2. 3. 4. Mail original petition to the Workers Compensation Board at the above address by regular mail. Mail one (1) copy by certified mail, return receipt requested to the insurance company. Mail one (1) copy by certified mail, return receipt requested to the employer. Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office. NAME OF PROVIDER'S ATTORNEY (IF ANY) Attorney(s) for STREET/P.O. BOX CITY, STATE, ZIP Office and P.O. Address THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES OR ACTIVITIES. THIS MATERIAL CAN BE MADE AVAILABLE IN ALTERNATE FORMATS BY CONTACTING YOUR DEPARTMENT S ADA COORDINATOR. WCB-190A (06/98) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com