LAC 40:III.501
LOUISIANA SECOND INJURY BOARD
REQUEST FOR REIMBURSEMENT—FORM B
| SIF CLAIM # | ||||
|---|---|---|---|---|
| EMPLOYEE: | DATE OF ACCIDENT: | |||
| CARRIER/SELF-INS | CARRIER’S CLAIM#: | |||
| EMPLOYER: | JCN #: | |||
| AMOUNT WEEKLY | FROM-TO DATES THIS SUBMISSION | TOTAL WEEKS | TOTAL AMOUNT PAID | |
| TTD | ||||
| PTD | ||||
| SEB | ||||
| DEATH | ||||
| TOTAL INDEMNITY PAID THIS SUBMISSION | $ | |||
| TOTAL MEDICAL BENEFITS PAID THIS SUBMISSION | $ | |||
| TOTAL SETTLEMENT (INDEMNITY + MEDICAL) PAID THIS SUBMISSION | $ | |||
| TOTAL WC BENEFITS PAID THIS SUBMISSION | $ |
THE FOLLOWING DOCUMENTATION MUST BE INCLUDED WITH THE FORM B SUBMISSION
INDEMNITY REIMBURSEMENT REQUEST
Electronic print-out of indemnity payments shall include: date of payment, payee, benefit dates (from/thru), amount paid, and check or ACH number
MEDICAL REIMBURSEMENT REQUEST
A. Electronic print-out of medical payments shall include: date of payment, payee, service dates (from/thru), amount paid, and check or ACH number
B. Copies of all medical bills or EOBs ordered and numbered to correspond with electronic print-out (shall include patient info, provider info, date of service, CPT codes, ICD codes, and amount charged)
SETTLEMENT REIMBURSEMENT REQUEST
Signed petition, Judgement, Receipt and Release, Order from OWCA and a copy of the check or electronic print-out of payment which shall include: date of payment, payee, amount paid, and check or ACH number
THIRD PARTY RECOVERY
IS THERE ANY POTENTIAL TO RECOVER ALL OR A PORTION OF THE BENEFITS PAID TO THE INJURED EMPLOYEE FROM A THIRD PARTY? YES NO
I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THIS REQUEST AND THE INFORMATION PROVIDED ON THIS FORM IS CORRECT AND ACCURATE TO THE BEST OF MY KNOWLEDGE:
________________________ ________________________ ________________
Signature Print Name Date
Company: ________________________ Telephone: ________________________
SIB Form B 9/17
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1310.1 and R.S. 23:1293.
HISTORICAL NOTE: Promulgated by the Workforce Commission, Office of Workers' Compensation Administration, LR 44:106 (January 2018).