Report of Medical Costs Submit to: 45 - G Virginia Workers’ Compensation Commission 1000 DMV Drive Richmond VA 23220 See instructions on the reverse of this form. Insurer Name of insurer or self-insurer Period covered From / Insurer code Address / To / Insurer location Contact Person / Date filed Phone number Payments NOTE: This report is to be filed every six months and SHOULD NOT include costs previously reported. 1. VWC File Number 2. Name of employee 5. Hospital costs 3. Social Security Number 7. Miscellaneous costs 8. Rehabilitative costs 3. Social Security Number 4. Date of accident 7. Miscellaneous costs 8. Rehabilitative costs 3. Social Security Number 4. Date of accident 7. Miscellaneous costs 8. Rehabilitative costs 3. Social Security Number 4. Date of accident 7. Miscellaneous costs 8. Rehabilitative costs 3. Social Security Number 4. Date of accident 7. Miscellaneous costs 8. Rehabilitative costs 3. Social Security Number 4. Date of accident 7. Miscellaneous costs 8. Rehabilitative costs 3. Social Security Number 6. Physician costs 4. Date of accident 4. Date of accident 7. Miscellaneous costs 8. Rehabilitative costs 1. VWC File Number 2. Name of employee 5. Hospital costs 6. Physician costs 1. VWC File Number 2. Name of employee 5. Hospital costs 6. Physician costs 1. VWC File Number 2. Name of employee 5. Hospital costs 6. Physician costs 1. VWC File Number 2. Name of employee 5. Hospital costs 6. Physician costs 1. VWC File Number 2. Name of employee 5. Hospital costs 6. Physician costs 1. VWC File Number 2. Name of employee 5. Hospital costs 6. Physician costs Report of Medical Costs VWC Form No. 45G (rev. 9/1/99) American LegalNet, Inc. www.FormsWorkflow.com FILING INSTRUCTIONS (Instructions Updated 09/01/07) Report of Medical Costs VWC Form No. 45G 1. This form is to be used to report medical costs on accidents that were previously reported to the Virginia Workers’ Compensation Commission on an Employer’s Accident Report (VWC Form No. 3) because they (a) result in lost time of more than seven days; (b) involve more than $1,000 in medical costs; or (c) involve any fatality, permanent disability, or disfigurement. This report is to be submitted every six months.* 2. The insurer or its designated representative should complete all of the information requested at the top of the form. 3. Type or legibly print all information on the form for each employee, including the VWC File Number, Social Security Number, and Date of Accident, along with a breakdown of the medical expenses incurred. Note: If you do not have a VWC File Number, please ensure that you have filed an Employer’s Accident Report (VWC Form No. 3) with the Commission 4. Incomplete or illegible forms will be returned to the sender for proper completion. 5. If no medical costs were incurred on a particular claim during the reporting period, these claims should not be submitted to the Commission reflecting a zero ($0) amount. 6. Forms: Additional copies of this form are available without cost by writing to the Commission. This form is also available on the Commission’s Website, at www.vwc.state.va.us. Address your inquiries to “Forms” at the listed Virginia Workers’ Compensation Commission address. Please note that any alternative versions of the form you develop require prior approval of the Commission. 7. Electronic Filing: The Report of Medical Costs (VWC Form No. 45G) can be filed electronically through the Commission’s Website at www.vwc.state.va.us and selecting Electronic Filing Services. If you are interested in the batch processing method, please contact our “Information Systems Department” at (804) 367-2084 or in writing. Please provide a brief description of you current data processing and communication capabilities. 8. For questions or assistance with completing this form, please contact the Awards Unit using the Commission’s Toll Free number at (1-877) 664-2566. __________________________________ *If this accident has not been previously reported to the Commission, and does not meet one of the following seven criteria, you should use VWC Form No. 45A (Report of Minor Injuries) rather than this report: (1) lost time exceeds seven days, (2) medical expenses exceed $1,000, (3) compensability is denied, (4) issues are disputed, (5) the accident resulted in death, (6) permanent disability or disfigurement may be involved, and (7) a specific request is made by the Virginia Workers’ Compensation Commission. American LegalNet, Inc. www.FormsWorkflow.com