FORM 19 Send Original to Court of Existing Claims and 1 copy to Insurance Carrier, Self-Insured Employer/Own Risk Group or Uninsured Employer COURT OF EXISTING CLAIMS 1915 NORTH STILES AVENUE OKLA. CITY, OK 73105-4918 THIS SPACE FOR COURT USE ONLY In re claim of: Full Name of Injured Employee (Claimant) Employee's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-____________________________ Name of Employer (Respondent) Please check ( ) the appropriate box I . REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES I I . NOTICE OF APPEAL OF COURT ADMINISTRATOR ORDER Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured Name of Provider WCC FILE NO. (Must be filled out) Date of Injury (Please type or print) Address of Employee (Claimant) Including Number & Street Address of Employer (Respondent) Including Number & Street Address of Provider Including Number & Street Provider's Telephone Number City City City State State State Zip Zip Zip NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. If the Form 19 is being filed to appeal an order issued by the Administrator of the Court of Existing Claims, please complete PART II ONLY. - PART I. REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES 1. 2. Total expenses to date for services rendered or medicines or supplies provided to claimant $ ____________________________________________________________ Date charges identified above were submitted to the claimant's self-insured employer, uninsured employer or the employer's workers' compensation insurance carrier (MUST be completed). __________________________, ________. Total Amount Received in Payment $________________________. If the dispute involves the length of treatment rendered, or relates to complex medical treatment rendered beyond applicable treatment guidelines, a narrative medical report explaining the treatment provided and the charges submitted, must be sent to the payer. DO NOT ATTACH A COPY OF ANY BILLS OR MEDICAL REPORTS WHEN FILING THE FORM 19 WITH THE COURT OF EXISTING CLAIMS. - PART II. NOTICE OF APPEAL OF COURT ADMINISTRATOR ORDER 1. File stamped date of Administrator's Order: ___________________________, ____________. Identify each portion of the Administrator's Order which is claimed in error and how it conflicts with the Schedule of Medical and Hospital Fees: 2. ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. I HEREBY CERTIFY THAT A COPY OF THIS FORM AND ALL RELEVANT BILLS AND MEDICAL REPORTS HAVE BEEN SENT TO: Self-Insured Employer/Own Risk Group Address (Number & Street) City State Zip Code Signed this _______ day of ____________________________, ___________ Signature of Provider Insurance Carrier Uninsured Employer Print or type Name of Attorney Representing Provider, if any Attorney Address (Number & Street) City State OBA# Zip Code C. 02/01/2014 Telephone Number of Attorney representing Provider ATTENTION: The Court of Existing Claims will not set this Form 19 for hearing unless it is attached to a Form 9, "Motion to Set for Trial" either as an original proceeding or as an appeal of an order of the Administrator of the Court of Existing Claims. American LegalNet, Inc. www.FormsWorkFlow.com