COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : : Plaintiff(s) -against- Index No. Calendar No. Bob Taft JUDICIAL SUBPOENA : Governor James Conrad Administrator/CEO : The Ohio Bureau of Workers’ Compensation 30 West Spring Street, Columbus Ohio 43215-2256 : Defendant(s) : ...................................................... REQUEST FOR THE OHIO BUREAU OF WORKERS’ COMPENSATION 2003 FEE SCHEDULE THE PEOPLE OF THE STATE OF NEW YORK Effective for dates of service on or after Jan 1, 2003, BWC will require 2003 CPT Billing Codes. With the requirement of 2003 CPT Billing Codes, BWC will also implement a fee schedule for HCPCS Level I (CPT), HCPCS Level II, and TO HCPCS Level III (Local) Codes. To obtain a copy of BWC’s 2003 Fee Schedule, complete the information below. Company/Business GREETINGS: _ Contact Person WEPhysical Address (cannot mail to a P.O Box) excuses being laid aside, you and each of you attend before COMMAND YOU, that all business and , the Honorable at the Court County of City, State, ZIP Code located at Telephone the in room , on Number day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Fax Number Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 2003 FEE SCHEDULE the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your2003 Fee Schedule is available in two formats. Check the format you wish to receive. The failure to comply. Witness, Honorable Court in County, Booklet (Hard Copy) $10 per, copy of the Justices of the one day of Downloadable 20 , diskette $10 per copy* * The downloadable diskette requires a signed CPT end user agreement between BWC and the requestor prior to (Attorney BWC will send the end user agreement to the distribution. Upon receiving the completed fee schedule application, must sign above and type name below) requestor. Requestor must sign and return end user agreement, along with the $10 fee to BWC. Attorney(s) for When ordering, please enclose a check for the appropriate amount. Make the check payable to Ohio Bureau of Workers’ Compensation. Please complete this form and return with a check to BWC’s Policy and Support department at: Ohio Bureau of Workers’ Compensation Policy and Support L-20 P.O. Address Office and 30 West Spring Street Columbus, OH 43215-2256 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com