STATE OF NEW YORK - WORKERS' COMPENSATION BOARD Disputed Medical Bills Unit 1-800-781-2362 PROVIDER'S REQUEST FOR JUDGMENT OF AWARD SECTION 54-b, Enforcement on Failure to Pay Award or Judgment Upon issuance of an administrative award and/or arbitration decision you must wait at least 30 days before requesting consent for judgment. To avoid the complications of filing unnecessary requests, waiting 60 days is recommended. The 60 day time period will allow for carriers' billing/payment cycles. This form may be used by an authorized workers' compensation provider whenever a carrier or self-insured employer has not paid for an award or decision (for awards/decisions made on or after March 13, 2007). Section 54-b of Workers' Compensation Law provides that in the event an insurance carrier or self-insured employer defaults in the payment of an award made by the Board, any party to an award may, with the Chair's consent (or the consent of the Chair's designee), file with the County Clerk for the county in which the injury occurred or the county in which the carrier or self-insured employer has its principal place of business, a certified copy of the decision that awarded compensation. Request for Consent and Certified Copy of Unpaid Award or Decision for Medical Care I request consent for judgment and a certified copy of the unpaid award or decision for WCB dispute number(s): ATTACH A COPY OF THE ORIGINAL AWARD(S) Name and Address of Health Care Provider Name 1 2 Address City State Zip Code WCB Case Number WCB Authorization Number Date of Accident or Injury Carrier Case Number Carrier/Self-Insured Employer I.D. Number County in Which Injury Occurred Name and Address of Carrier/Self-Insured Employer Name 1 2 Address City State Zip Code Employer - Affirmation of Non-Payment PHYSICIANS COMPLETE THE FOLLOWING: I state that I am a physician, authorized by law to practice in the State of New York, am not a party to this proceeding, am the physician not remunerated for the above award(s) or decision(s), have read and know the contents thereof; that the same is true to my knowledge, except as to the matters stated to be on information and belief, and as to those matters I believe it to be true. Affirmed as true under the penalty of perjury. Written Signature (Facsimile not Accepted) ________________________________ Date ________________________ ALL OTHERS COMPLETE THE FOLLOWING: IMPORTANT: BY LAW THOSE COMPLETING THIS SECTION MUST BE SWORN TO BEFORE A NOTARY PUBLIC. I state that I am a chiropractor, authorized hospital representative, physical or occupational therapist, podiatrist or psychologist, authorized by law to practice in the State of New York and/or authorized to represent a hospital, am not a party to this proceeding, am the provider or representative of a hospital not remunerated for the above award(s) or decision(s), have read and know the contents thereof; that the same is true to my knowledge, except as to the matters stated to be on information and belief, and as to those matters I believe it to be true. Affirmed as true under the penalty of perjury. Written Signature (Facsimile not Accepted) ________________________________ Date ________________________ State of New York ) ss: County of ___________________________________ ) _________________________________________, being duly sworn, deposes and says: That (s)he is the _________________________, duly licensed in the State of New York and/or authorized to represent a hospital, who has not been remunerated for the above award(s) or decision(s), and that (s)he has read the same and knows the contents thereof; that the same is true to the knowledge of the deponent, except as to the matters stated to be on information and belief, and as to those matters (s)he believes it to be true. Subscribed and sworn before me this ________________________ day of _________________________, _______ _________________________________________ (Signature of Notary Public) HP-J1 (7-08) Mail completed form to: Workers' Compensation Board Disputed Medical Bills Unit 328 State Street American LegalNet, Inc. Schenectady, NY 12305 www.wcb.ny.gov www.FormsWorkFlow.com