FORM 10M Send original to Workers’ Compensation Court and 1 copy to Claimant/Claimant’s Counsel and 1 copy to Health/Rehabilitation Provider In re claim of: WORKERS’ COMPENSATION COURT 1915 NORTH STILES OKLA.CITY, OKLAHOMA 73105-4918 THIS SPACE FOR COURT USE ONLY Full Name of Injured Employee (Claimant) Claimant’s Social Security Number Name of Employer (Respondent) RESPONSE TO REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured Name of Claiming Provider FILE NO. Provider’s Address Date of Injury (Must be filled out) (Please Type or Print) Address of Employee (Claimant): Number & Street City State Zip Code Address of Employee (Respondent): Number & Street City State Zip Code NOTE: Mediation is available to address certain workers’ compensation disputes. For information, call (405) 522-8760 or in-state toll free (800) 522-8210. YES NO ________ ________ 1. Has payment been refused? 2. Grounds for the refusal of payment? ________ ________ a. necessity of treatment rendered. ________ ________ b. unauthorized physician. ________ ________ c. denial of compensability of the claimant’s accidental injury or occupational disease. ________ ________ d. other, including affirmative defenses (explain)____________________________________________________________________ ________ ________ 3. Was provider notified of refusal of payment within 60 days? ________ ________ 4. Has an order from the Workers’ Compensation Court been issued regarding the compensability of the claimant’s request for compensation? Date of order ________________________________________________________________________________ ________ ________ 5. Has the claimant’s request for benefits been resolved by Settlement or Agreement of the parties? Date of Settlement or Agreement _____________________________________________________________________________ ________ ________ 6. Has claimant been provided Temporary Total Disability benefits? Date TTD benefits provided: _______________to______________ 7. List all other medical providers in this claim which are in dispute: Medical/Rehabilitation Provider______________________________________________ __________________________________________________________________________________________________________________________ 8. List the names of all witnesses who may be called by respondent at trial: ________________________________________________________________ __________________________________________________________________________________________________________________________ 9. List all exhibits to be introduced at trial: ___________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ If the dispute involves the length or necessity 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 opposing the treatment provided and/or the charges submitted must be sent to the health/rehabilitation provider. Do NOT attach a copy of the medical report when filing the Form 10M with the Workers’ Compensation Court. 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. Signed this________________day of______________________,___________. I HEREBY CERTIFY THAT A COPY OF THIS FORM AND ALL RELEVANT MEDICAL REPORTS HAVE BEEN SENT TO: Claimant Health/Rehabilitation Provider Address (Number & Street) City State Signature of Responding Party Address (Number & Street) City Zip Code State Zip Code Telephone # of Responding Party Print or type name of Attorney OBA # 2/06 American LegalNet, Inc. www.USCourtForms.com