State of New York WORKERS' COMPENSATION BOARD COVER SHEET: LIST OF ITEMIZED MEDICAL BILLS IN CONTROVERTED WORLD TRADE CENTER CASE ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS WCB Case Number Carrier Case Number Date of Accident Name Claimant's Date of Birth Social Security Number Address Injured Person Employer Insurance Carrier DATE OF FILING OF C-7 _____________________ This claim has been controverted by the self-insured employer or insurance carrier. Based upon a review of the case and in the interest of justice, the Board has directed the World Trade Center Volunteer Fund to pay all medical bills pertaining to the subject injury or condition without prejudice pending adjudication and resolution of all threshold issues. The self-insured employer or insurance carrier is therefore directed to submit to the Board within 15 days and monthly thereafter an itemized list of all medical bills to be paid detailing the date of treatment, name and address of the medical provider, diagnostic codes and the amount of the outstanding medical bill(s). An example is set forth below. Medical bills and reports must be attached to the list. This form letter MUST accompany each itemized list with attachments sent to the Board on a monthly basis for payment. Health Providers must still request authorization for special medical services costing more than $1,000 from the self-insured employer or insurance carrier. The self-insured employer or insurance carrier is directed to timely respond to all requests for authorization for special medical services pursuant to the procedures outlined in WCL 13-a(5) and 12NYCRR 325-1.4(b). Health Providers must continue to forward medical bills to the self-insured employer or insurance carrier of record. Reimbursement for pharmaceutical expenses will be accepted, although reimbursement for claimants' travel allowances will not be payable from this fund. Sample Itemized List of Medical Bills Date of Treatment Name of Medical Provider Address of Medical Provider Diagnostic Codes Prepared by Dated Official Title Amount of Outstanding Medical Bills Telephone No. & Extension WTC-16 (7-07) www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkflow.com