State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION MEDICARE CONDITIONAL PAYMENT ADDENDUM (SETTLEMENT) Petitioner: CASE NUMBER(S) : VICINAGE: Respondent: Petitioner is Medicare entitled. The Center for Medicare Services (CMS) has been contacted for an itemization of monies, if any, CMS paid for the compensable condition(s). As of this date, the CMS conditional payment review is pending. All parties agree that should they not be able to amicably resolve the responsibility for reimbursement to CMS, this Court retains jurisdiction to determine the extent to which the respondent is liable for payment to CMS for medical treatment. All parties recognize that this court has no jurisdiction to determine the total amount due CMS. Petitioner understands that he/she may be held personally liable to reimburse CMS for treatment paid for by Medicare but held not to be the responsibility of the Respondent, possibly beyond the settlement amount. _______________________________________________________________________ JUDGE OF COMPENSATION DATE WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE A COPY _____________________________________________________________ PETITIONER’S ATTORNEY _________________________________________________________ RESPONDENT’S ATTORNEY _____________________________________________________________ PETITIONER (Where Applicable) WCAmerican LegalNet, Inc. www.FormsWorkFlow.com