PROVIDER ' S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: ER HEALTH CARE PROVIDER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: EMPLOYEE NAME: LAST FOUR DIGITS SSN: XXX-XX- DATE OF INJURY: BOARD FILE NUMBER: NAME: STREET/P.O. BOX: CITY, STATE, ZIP: NOTICE When there is no ongoing dispute, if bills for medical or health care services are not paid within 30 days after the carrier has received notice 1.On , sustained a work-related MONTH 2.The treatment includedDESCRIBE THE TREATMENT PROVIDED for the employee222s injured . LIST BODY PARTS INJURED 3.The charges related to the medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aidsprovided for treatment of the employee222s work-related injury or disease are as set forth on the attached bills (do notTHEREFORE, the provider asks the board to order benefits pursuant to Title 39 or 39-A. SIGNATURE OF PETITIONER FILING INSTRUCTIONS 1. Mail original petition to the Workers222 Compensation Board at theabove address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested, to3 .Keep one (1) copy for yourself and keep the green certified mailcards when returned to you by the U.S. Post Office. DATED: MONTH DAY YEAR NAME OF PROVIDER222S ATTORNEY (IF ANY) STREET/P.O. BOX CITY, STATE, ZIP TELEPHONE NUMBER The State of Maine provides equal opportunity in employment and programs.American LegalNet, Inc. www.FormsWorkFlow.com