Fill and Sign the Form 24 Nc Industrial Commission Ncgov

       1                                   2                                   .3                                   4                                   5                                   6                                   7                                   8                                   9                                   10                                   11                                   12                                   13                                   14                                   15                                                                                                I.C. File No. Emp. Code No. Carrier Code No. Carrier File No. Employee: Employer:            As a result of examination made on and I certify the injured able to return to work on General Remarks: Date at (Signed) Identifying Number Form No. 25D Revised 2/96 THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE WORKERS' COMPENSATION ACT NORTH CAROLINA INDUSTRIAL COMMISSION RALEIGH The I.C. File No. is the unique DENTISTS ITEMIZED STATEMENT OF CHARGE FOR TREATMENT identifier for this injury. It and should be used on all future correspondence. CERTIFICATION OF TREATMENT OF DISABILITY Code numbers assigned toeach employer and carriershould be inserted beforemailing. Date of Accident- Nature of Injury :31. Examination and treatment plan - List in order from tooth no, I through tooth no. :32 Use charting system shown. 1-1.1 Tooth Surface Description of service(including x-rays, prophylaxis, materials used, etc)Line No. Date service Procedure Fees For # or performed number administrative letter Mo. Day Year use only V .11- INDICATE MISSING TEETH WITH AN 'X' REMARKS FOR UNUSUAL SERVICES All work must be fully detailed: Type of crowns, description of bridges, and design of partials.Including materials used. Please indicate on chart the work performed. TOTAL Please refer to N.C.I.C. medical fee schedule for C. P. T. codes for x-rays and surgery performed. Injured requires further treatment as here described --- . . .- , I hereby certfiy that disability resulting from the above injury has terminated, PERMANENT Disability is as follows-Has this accident resulted in any PERMANENT Disability9 Describe any pre-existing disability (state extent) (Show Place and Date) (Attending Dentist) Bill for Dental Services Must be Presented in Duplicate on This Form. Be Specific. No Other bill Servic es is Required. Give Full Explanation ofAny Charges in Excess of Published Fee Schedule. Please Submit Through Office of the Insurance. Carrier.