C-251.6 (8-19) THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION Carrier Code / Carrier Name: Claim Administrator: Contact Name: Phone Number: Email: Submit Date: Carrier's Request for Reconsideration of Reduction Under WCL Section 14(6) or Section 15(8) Email completed form to: SpecialFunds@wcb.ny.govSubmission of this form is a certification to the Chair of the Workers' Compensation Board that the amount of reimbursement requested is the same as that which was expended, that all payments were made in accordance with the applicable Medical Fee Schedule and Medical Treatment Guidelines, that no part thereof has been previously reimbursed, that the amount stated herein is due and owing, and that the information contained herein is true and correct. Invalid or inaccurate requests may be subject to penalty. Claim Information WCB Case Number Claimant Name Carrier Case Number Request Summary Reference Number Begin Date End Date Requested Amount Original Amount Explanation Enter information in support of the request for reconsideration in the space provided. A single page document may be attached as an addendum and, if not previously submitted, relevant supporting evidence may be attached to the form (see instructions for further details). Failure to follow these instructions may result in rejection of the request for reconsideration. American LegalNet, Inc. www.FormsWorkFlow.com C-251.6 INSTRUCTIONS (8-19) SUBMISSION INFORMATION Carrier Code - Enter the WCB-assigned Carrier Code ("W Number") for the carrier that is responsible for the claim and seeking reimbursement; this entity must be identified as a Party of Interest (POI) on the claim in the WCB case folder in order for reimbursement to be processed [REQUIRED]. Carrier Name - The form will populate the name of the carrier that is responsible for the claim and seeking reimbursement from the name in Groups tab. Claim Administrator - Enter the name of the entity that is administering the claim and will receive the reimbursement or indicate if claim is self-administered; this entity must be identified as a POI on the claim in the WCB case folder in order for reimbursement to be processed. Payment will be directed to the address the WCB Special Funds Group has on file for the administrator [REQUIRED]. Contact Name - Enter the name of the person that the WCB Special Funds Group can contact with questions about the submission [REQUIRED]. Phone Number - Enter the phone number for the contact [REQUIRED]. E-Mail Address - Enter the e-mail address for the contact [REQUIRED]. Submit Date - Enter the date the form was submitted to the WCB Special Funds Group [REQUIRED]. CLAIM INFORMATION WCB Case Number - Enter the claim number assigned by WCB; this number should be entered as it appears in eCase with no spaces or extra characters [REQUIRED]. Carrier Case Number - Enter the claim number assigned by the carrier [OPTIONAL]. Claimant Name - Enter the name of the claimant [REQUIRED]. REQUEST SUMMARY Reference Number - Enter the reference number assigned to the original request by Special Funds Group. This number appears on Form C-251R and Form C-251.1R [REQUIRED]. Begin Date - Enter the begin date of the original request [REQUIRED]. End Date - Enter the end date of the original request [REQUIRED]. Original Amount - Enter the amount of the original request [REQUIRED]. Requested Amount - Enter the amount that reconsideration is being requested for; this amount cannot be greater than the difference between the amount of the original request and the amount that was approved by Special Funds Group for that request [REQUIRED]. EXPLANATION Provide a brief statement of the particular grounds upon which the request for reconsideration is based. A one-page document may be attached as an addendum, using 12-point font, with one inch margins, on 8.5-inch by 11-inch paper. An addendum longer than one page will not be considered, unless the carrier specifies in writing, why the basis of the request could not have been made within the space provided and the one-page addendum. Additional supporting evidence may be submitted if such evidence has not been submitted previously and is not already available for consideration in the Board's electronic case folder. The number of additional documents submitted shall not exceed the number of medical bills at issue and/or, more than ten pages where the request involves indemnity reimbursement. Additional information can be found on the WCB website: www.wcb.ny.gov . American LegalNet, Inc. www.FormsWorkFlow.com