North Carolina Industrial Commission ANNUAL CONSOLIDATED FISCAL REPORT OF "MEDICAL ONLY" AND "LOST TIME" CASES The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Emp. Code # Carrier Code # It is the responsibility of the Carrier, Self-Insured Employer, Group Self-Insured as certified by the N.C. Department of Insurance and Statutory Self-Insured (State Agencies and Political Subdivisions) to submit a consolidated fiscal report yearly to the N.C. Industrial Commission on medical expenses paid without prior submission of the billings to the Commission, due to (1) the charges having been incurred in "medical only" cases, (2) application of the Commission's Fee Schedule by an approved firm, or (3) payment pursuant to a contract with a Managed Care Organization exempt from the Fee Schedule. An MCO, Third Party Administrator, or service company may file on behalf of these parties. A Form 51 covering the preceding July 1 - June 30 shall be submitted on or before July 30 of each year. Name and Code # of Carrier, Self-Insured Employer, Group Self-Insured as certified by the North Carolina Department of Insurance, or Statutory Self-Insured (State Agencies and Political Subdivisions) # All Must Complete The Following 1. Total Number Of "Medical Only" Cases: 2. Total Amount Paid "Medical Only" Cases: $ Complete The Following Section Only If You Are A Managed Care Insurer Or Are Directly Applying The Industrial Commission Medical Fee Schedule To Submitted Medical Bills: (Exclude "Medical Only") 3. 4. 5. 6. 7. 8. Total Number Of "Lost Time" Cases: Total Hospital -- Outpatient paid: Total Hospital -- Inpatient paid: All other Providers, excluding Rehabilitation: Total Amount Paid For Rehabilitation: Total Medical Comp. Paid (Add lines 4-7): $ $ $ $ $ Address Of Submitting Office: REPORTING YEAR: JULY 1, 20__ THROUGH JUNE 30, 20__ MAIL TO: FORM 51 07/13 PAGE 1 OF 1 FORM 51 NCIC - STATISTICS SECTION 4334 MAIL SERVICE CENTER RALEIGH, NC 27699-4334 TELEPHONE: (919) 807-2506 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ American LegalNet, Inc. www.FormsWorkFlow.com