Request For Additional Palliative Care
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Request For Additional Palliative Care Form. This is a Rhode Island form and can be use in Department Of Labor And Training Workers Comp.
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Tags: Request For Additional Palliative Care, DWC-40, Rhode Island Workers Comp, Department Of Labor And Training
State of Rhode Island
REQUEST FOR ADDITIONAL PALLIATIVE CARE
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
DWC No.
Department of Labor and Training, Division of Workers' Compensation
PO Box 20190, Cranston, RI 02920-0942
Phone (401) 462-8100 TDD (401) 462-8006
Insurer File No.
Medical Provider complete 1-7
You must send this request to the claim administrator at least ten (10) working days prior to the delivery of services, with a copy to the employee.
1. EMPLOYEE:
2. EMPLOYER:
SSN
Name
Address
City, State, Zip
Phone
Date of Birth
FEIN
Name
Address
City, State, Zip
Phone
3. CLAIM ADMINISTRATOR:
(Party managing the claim ex: Insurer)
4. MEDICAL PROVIDER:
FEIN
Name
Address
City, State, Zip
Phone
Ext.
5. INJURY INFORMATION:
Injury date:
Ext.
FEIN
Name
Address
City, State, Zip
Phone
Ext.
Date maximum medical
improvement (MMI) reached:
6. DATE INFORMATION:
Date of this request:
Date delivery of service is planned:
7. TREATMENT PLAN INFORMATION: (If necessary, attach additional pages)
Treatment Plan:
Measures to Evaluate Objectives:
Timetable and Projected End Date:
Estimated Total Cost of Services:
Medical Provider Signature:
Date:
Claim Administrator Complete:
8. Request for Additional Palliative Care has been:
Approved
Modified
Denied
9. Treatment plan has been modified or denied for the following reason(s):
Print Adjuster Name:
Date:
A copy of this completed form shall be forwarded by the claim administrator to the RI Department of Labor and Training, Division of Workers’ Compensation,
and the employee and his or her attorney within ten (10) working days of the request for additional palliative care. Either party has a right to a review of any
decision regarding additional palliative care by the Workers' Compensation Court, pursuant to RIGL §28-35-11.
DWC-40 (04/05)
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