W.C.C. # of pending petitions: __________________________ __________________________ State of Rhode Island and Providence Plantations Providence, SC. Workers’ Compensation Court W.C.C. # Health Care Provider: ________________________ Employee to whom services were furnished: ___________________________________ ___________________________________ Health Care Provider-Petitioner Patient Name ___________________________________ ___________________________________ Address Address ___________________________________ ___________________________________ XXX-XX-__________________________ Social Security Number (last four digits only) -V- Employer: Insurance Carrier: ___________________________________ ___________________________________ Employer Name Insurer Name ___________________________________ ___________________________________ Address Address ___________________________________ ___________________________________ Agent for Service of Process (if a corporation or partnership): ___________________________________ Agent of Service Name ___________________________________ Address ___________________________________ Petition For An Order Concerning Payment For Medical Services The petitioner requests an order for the payment of medical or related services, as defined in the Workers’ Compensation Act, which were furnished by the petitioner to the above named injured employee, and in support of this petition states: 1. The above named employer is liable for the payment of such medical and related services by reason of an agreement or decree concerning compensation. A copy of said agreement or decree establishing such liability is attached hereto. 2. The services furnished were necessary in order to cure, rehabilitate or relieve said employee from the effect of an injury which was sustained on (Date of Injury) __________________or from the effect of an occupational disease which caused disablement on said date. 3. The petitioner has complied with all requirements of the Workers’ Compensation Act concerning notice, reports, bills, and permission for surgery, if applicable, pursuant to R.I.G.L. § 28-33-5 through § 28-33-10. 4. An itemized bill and corresponding reports in triplicate, showing dates, C.P.T. codes, nature of services, charges, and credits for any payments received, is filed herewith, pursuant to R.I.G.L. § 28-33-8 (f)(1). 5. That twenty-one (21) days have passed since request for payment upon the employer or insurer or written notice to the employer or insurer of their failure to fulfill the obligation pursuant to R.I.G.L. § 28-33-8. Name, Address, Phone Number and Bar Registration Number of Attorney for Petitioner ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Petitioner Date File the original and three copies with the appropriate attachments with the Office of the Administrator of the Workers’ Compensation Court, J. Joseph Garrahy Judicial Complex, One Dorrance Plaza, Providence, Rhode Island 02903-3973. Rev 02/08 Distribution: White: Court Yellow: Employee Pink: Employer Gold: Insurer American LegalNet, Inc. www.FormsWorkflow.com