Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper)
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Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper) Form. This is a New York form and can be use in Workers Compensation.
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Tags: Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper), C-251.1, New York Workers Compensation,
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
CARRIER'S REQUEST FOR REIMBURSEMENT OF MEDICAL EXPENSES UNDER SEC. 15-8
WCB CASE NO.
CARRIER CASE NO.
CARRIER ID NO.
SOC. SEC. NO.
W
CARRIER'S NAME
CARRIER'S ADDRESS
CLAIMANT'S NAME
In support of this request the following statements are submitted:
MEDICAL EXPENSES:
Paid for treatment rendered during period from______________________________ To_______________________.
(Receipted bills or photocopies must be attached to original copy.)
TOTAL $_____________________
STATEMENT
I hereby certify that this request for reimbursement made to the Chairman of the Workers' Compensation Board is true
and correct; that no part thereof has been previously paid and the amount stated therein is due and owing.
Signature:_____________________________________________________ Date:______________________________
Title:______________________________________________ Telephone No.:_____________________________
DO NOT USE SPACE BELOW
INSTRUCTIONS:
1. Where possible, claim should be submitted
for 26 week periods.
2. Forward original and two copies to the local office
of the Special Funds Conservation Committee.
3. Retain one copy.
TO: CHAIRMAN, WORKERS' COMPENSATION BOARD
The Special Funds Conservation Committee approves reimbursement for the above
claim totaling $_____________________.
Agreed Date for Medical Reimbursement_________________________________
By_______________________________
Date__________________________
C-251.1 (11-01)
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