Fill and Sign the Court of Existing Claims and 1 Copy to Form

Signature of Responding Party FORM 10M Send original to Court of Existing Claims and 1 copy to Claimant/Claimant’s Counsel and 1 copy to Health/Rehabilitation Provider COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLA.CITY, OKLAHOMA 73105-4918 In re claim of: RESPONSE TO REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES WCC FILE NO. Date of Injury (Must be filled out) (Please Type or Print) I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and comple te. Any person who commits workers’ compensation fraud, upon co nviction, shall be guilty of a felony. Rev. 06/24/2015 NOTE: Mediation is available to address certain workers ’ compensation disputes. For information, call (918) 581- 2714. Claimant Health/Rehabilitation Provider Address (Number & Street) City State Zi p Code Address (Number & Street) Telephone # of Responding Party Print or type name of Attorney OBA # I HEREBY CERTIFY THAT A COPY OF THIS FORM AND ALL RELEVANT MEDICAL REPORTS HAVE BEEN SENT TO: Signed this________________day of______________________ ,___________. YES NO ________ ________ 1. Has payment been refused? 2. Grounds for the refusal of payment? ________ ________ a. necessity of treatment rendered. ________ ________ b. unauthorized physician. ________ ________ c. denial of compensability of the claimant’s accidental injury or occupational disease. ________ ________ d. other, including affirmative defenses (explain)____________ ___________________________________________________ _____ ________ ________ 3. Was provider notified of refusal of payment within 45 da ys? ________ ________ 4. Has an order from the Court of Existing Claims been issued regarding the compensability of the claimant’s reques t for compensation? Date of order ___________________ _______________________________________________________________ ________ ________ 5. Has the claimant’s request for benefits been resolved by Settlement or Agreement of the parties? Date of Settlement or Agreement ________________ ________________________________________________________________ ________ ________ 6. Has claimant been provided Temporary Total Disability benef its? Date TTD benefits provided: _______________to______________ 7. List all other medical providers in this claim which are in dispute: Medical/Rehabilitation Provider___________________ ____ _______________________ __________________________________________________________________________________________________________________________ 8. List the names of all witnesses who may be called by respondent at trial: ________________________________ ________________________________ __________________________________________________________________________________________________________________________ 9. List all exhibits to be introduced at trial: ___________ ___________________________________________________ _____________________________ ___________________________________________________ ___________________________________________________ ______________________________________ Full Name of Injured Employee (Claimant) Claimant’s Social Security Number (LAST 4 DIGITS ONLY) XXX -XX -__________________ Name of Employer (Respondent) Employer’s Insurance Carrier, Permit # for Court Approved Individual S elf-Insured or Own Risk Group, Uninsured Name of Claiming Provider Provider’s Address Address of Employee (Claimant): Number & Stre et City State Zip Code Address of Employer (Respondent): Number & Stree t City State Zip Code If the dispute involves the length or necessity of treatment rendered, or relates to complex medical treatment rendered beyond applicable treatment guidelines, a narrative medical report opposing the treatment provided and/or the char ges submitted must be sent to the health/rehabilitation provider. Do NOT attach a copy of the medical report when filing the Form 10M with the Court of Existing Claims. City State Zip Code THIS SPACE FOR COURT USE ONLY