THIS SPACE FOR COURT USE ONLY WORKERS’ COMPENSATION COURT 1915 NORTH STILES AVENUE OKLA. CITY, OK 73105-4918 FORM 19 Send Original to Workers’ Compensation Court and 1 copy to Insurance Carrier, Self-Insured Employer/Own Risk Group or Uninsured Employer In re claim of: Please check ( ) the appropriate box Full Name of Injured Employee (Claimant) Employee’s Social Security Number I . REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES Name of Employer (Respondent) I I . NOTICE OF APPEAL OF ADMINISTRATIVE ORDER Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured FILE NO. (Must be filled out) Name of Provider Date of Injury (Please type or print) Address of Employee (Claimant) Including Number & Street City State Zip Address of Employer (Respondent) Including Number & Street City State Zip Address of Provider Including Number & Street City State Zip Provider’s Telephone Number NOTE: Mediation is available to address certain workers' compensation disputes. (800) 522-8210. For information, call (405) 522-8760 or in-state toll free If the Form 19 is being filed to appeal an order issued by the Administrator of the Workers’ Compensation Court, please complete PART II ONLY. - PART I. REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES 1. Total expenses to date for services rendered or medicines or supplies provided to claimant $ ____________________________________________________________ 2. 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 the limitation of the Schedule of Medical and Hospital Fees, a narrative medical report explaining the treatment provided and the charges submitted, must be sent to the payor. DO NOT ATTACH A COPY OF ANY BILLS OR MEDICAL REPORTS WHEN FILING THE FORM 19 WITH THE WORKERS’ COMPENSATION COURT. - PART II. NOTICE OF APPEAL OF ADMINISTRATIVE ORDER 1. File stamped date of Administrative Order: ___________________________, ____________. 2. Identify each portion of the Administrative Order which is claimed in error and how it conflicts with the Schedule of Medical and Hospital Fees: _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 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 HAS BEEN SENT TO: Signed this _________________ day of _____________, ___________ Signature of Provider Self-Insured Employer/Own Risk Group Insurance Carrier Uninsured Employer OBA# Attorney Address (Number & Street) Address (Number & Street) City Print or type Name of Attorney Representing Provider, if any State Zip Code City State Zip Code Telephone Number of Attorney representing Provider 2/06 ATTENTION: The Workers’ Compensation Court 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 Workers’ Compensation Court. American LegalNet, Inc. www.USCourtForms.com