Fill and Sign the Fillable Online Wkc 12 Edoc Fax Email Print pdfFiller Form

Complete this form before the prehearing conference ( if one is scheduled) and update it before the formal hearing. Bring this form to both the conference and hearing. NOTE: An itemized statement for each expense claimed must be attached to this form and provided to the W orker’s Compensation Division and other parties to this case at least 15 days before the hearing, according to section 102.17(8) of the statutes. *Provision of your Social Security Number (SSN) is volunta ry. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m) , Wisconsin Statutes]. WC Claim Number Employee Name Employee Social Security Number * Employer Name Injury Date Insurance Company Name Have You A pplied For Or Are You Receiving Social S ecurity Benefits? Yes No Have You Applied For Or Are You Covered Under Medicare? Yes No If Yes, Medicare Claim Number: Names of Providers of Treatment, Medicati on, or Supplies Total Charges Amount Paid By Applicant Amount Paid By Other Insurance Carriers (Give Carriers’ Names ) Unpaid Balance $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL : $ $ $ $ WKC -3 (R. 06/201 7) Department of Workforce Development Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 -7901 Imaging Server Fax: (608) 260 -2503 Telephone: (608) 266 -1340 Fax: (608) 267 -0394 http:// dwd. wisconsin .gov /wc e-mail: DWDDWC@dwd. wisconsin.gov MEDICAL TREATMENT STATEMENT SUPPLIES AND MEDICATIONS