LAC 40:I.2328
E-Mail to: mgd1009@lwc.la.gov 1. Last four digit of Social Security No. ___________
Fax to: OWCA – Medical Services 2. Date of Injury/Illness _____-_____-________
ATTN: Medical Director 3. Parts of Body Injured_________________________
(225) 342-9836 _____________________________________
Mail to: Medical Services 4. Date of Birth _______-______- _______
P.O. Box 94040 5. Date of This Request _______-______-________
Baton Rouge, LA 70804 6. Claim Number _____________________________
DISPUTED CLAIM FOR MEDICAL TREATMENT (1009)
A. The insurer has issued a denial;
B. The insurer has issued an approval with modification;
C. The insurer’s failure to act has resulted in a deemed/tacit denial; or
D. The aggrieved party is seeking a variance from the medical treatment schedule
DISPUTES RELATING TO COMPENSABILITY AND/OR CAUSATION ARE NOT ADDRESSED BY THE MEDICAL DIRECTOR.
GENERAL INFORMATION
An aggrieved party files this dispute with the Office of Workers’ Compensation – Medical Services Director by mail, email or fax. This office must be notified immediately in writing of changes in address. An employee may be represented by an attorney, but it is not required. The completed LWC-WC-1009 must be submitted to OWCA within 15 calendar days of the 1010 denial, 1010 approval w/modification or 1010 deemed/tacit denial. A deemed/tacit denial is when a carrier/self-insured employer fails to return the LWC-WC-1010 form within five business days of submission of the form to the carrier/self-insured employer.
7. This request is submitted by:
Employee/Employee’s Attorney Health Care Provider Other: _____________________
The following records/documents MUST be attached to this request. Failure to do so may result in the rejection of the request by the OWCA Assistant Secretary:
A. Copies of all relevant information must be included with this request as per LAC 40:I.2715 (J) including a copy of the LWC-WC-1010 and all of the information previously submitted to the carrier/self-insured employer.
B. If applicable, a copy of the denial letter issued by the insurance carrier or utilization review company.
C. Include scientific medical evidence when seeking a variance.
EMPLOYEE EMPLOYEE’S ATTORNEY (if any)
8. Name ____________________________ 9. Name ______________________________
Street or Box ______________________ Street or Box _________________________
City _____________________________ City ________________________________
State ____________________ Zip _______ State ___________________ Zip _________
Phone (_____) _______________________ Phone (_____) ________________________
Fax (_____) ________________________
Email ________________________________
Employer Insurer/Administrator
(circle one)
10. Name _____________________________ 11. Name ______________________________
Street or Box ________________________ Street or Box ________________________
City _______________________________ City _______________________________
State __________________ Zip ________ State ___________________ Zip ________
Phone (_______) _____________________ Phone (_____) _______________________
Fax (_______) _______________________
Email ______________________________
Treating/Requesting Physician EMPLOYER/INSURER ATTORNEY
12. Name ______________________________ 13. Name _____________________________
Street or Box _________________________ Street or Box ________________________
City ________________________________ City _______________________________
State ____________________ Zip ________ State ___________________ Zip ________
Phone (_____) ________________________ Phone (_____) _______________________
Fax (_____) ________________________ Fax (_____) _______________________
Email _______________________________ Email ______________________________
14. PLEASE PROVIDE A SUMMARY OF THE DETAILS REGARDING THE ISSUE AT DISPUTE:
(If requesting a variance, explain here)
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You may attach a letter or petition with additional information with this disputed claim.
By signing below, you are certifying that this form along with all supporting documentation has been sent to the carrier/self-insured employer this date by e-mail or fax.
The information given above is true and correct to the best of my knowledge and belief.
_________________________________________ _____________________
SIGNATURE OF REQUESTING PARTY (Required) DATE
___________________________________________________
Printed Name of Requesting Party
NOTE: THIS REQUEST WILL NOT BE HONORED UNLESS THERE ARE MEDICAL SERVICES IN DISPUTE AS PER R.S. 23:1203.1 J AND THE FOLLOWING HAS OCCURRED:
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 38:3254 (December 2012), amended LR 51:85 (January 2025), amended by Louisiana Works, Office of Workers’ Compensation Administration, LR 52:509 (April 2026).