Fill and Sign the Form Ar L Arkansas Workers Compensation

Form AR-MARKANSAS WORKERS’ COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 M Authority: Ark. Code Ann. § 11-9-528, 529 AWCC Rule 8 Revised: 1-1-2001 MONTHLY REPORT ON MEDICAL - ONLY INJURY DATA TO BE COMPLETED BY CARRIERS AND SELF-INSURED EMPLOYERS EACH MONTH ON CASES NOT OPENED BY FORM 1 OR FORM C. Report Period (Month, Year)Carrier or Self-Insured NameFEIN No. Claim Office/TPA Filing ReportMailing AddressCityStateZip Code MONTHLY MEDICAL-ONLY INJURY DATA Total No. of Medical-Only Injury Reports ReceivedTotal No. of Days LostTotal Medical Expense Give Total Number of Reported Injuries by Body Part (Must Equal Total No. of Injuries Reported Above) Head, Face and Neck: Eyes, Ears, Nose and Mouth: Hands, Arms and Fingers: Back and Hip: Chest and Lungs: Legs, Feet and Toes: Abdomen: Other or Multiple: CERTIFICATION I certify that the foregoing is a complete and accurate report for the above referenced carrier or self-insured employer of all medical-only claims reported and paid by that entity for the report period. SignaturePrinted or Typewritten Name TitleDateTelephone Number (including Area Code) (See Instructions on Back of This Sheet) M Help with the Form M is available from the Research and Statistics Section. General information is available from the Support Services Division (1-800-622-4472 or 501- 682-3930).AWCC Form M (Monthly Report on Medical-Only Injury Data) Instructions for Form M: 1. Send Form M to the AWCC Research & Statistics Section after the close of each month and by the 15th day of the next month. 2. Spell out the name of the carrier or self-insured; do not abbreviate. 3. Count calendar days lost rather than just work days. 4. All accidents/injuries resulting in disability of more than seven days, death cases, or those involving payment of weekly compensation shall be reported to the Commission on Form 1. In the event cases reported as medical-only develop into compensable cases, these previously-counted totals should be subtracted in subsequent Form M Monthly Reports. 5.All accidents/injuries, other than death, resulting in disability of seven days or less, must be reported on this form. This report is to be completed by all insurance carriers and self-insured employers providing workers’ compensation coverage in Arkansas. Companies/employers that have coverage with an insurance carrier are not required to complete this form. 6.Report expenses each month. When medicals are carried over into another month, expenses should be included on future M Forms, but the accident should only be counted once. 7.Separate reports must be submitted for each separate carrier or self-insured FEIN number. 8.Third-party administrators/service companies should NOT complete this form unless designated to do so by the carrier or self- insured. Reports with “No Activity” during the period must be completed and so indicated. 9.NOTE: The Commission has the authority to levy a fine up to $500 per report per carrier or self-insured FEIN for failure to submit or late submittal of this form. FAX reports are acceptable. The fax number is (501)682-2777. Ark. Code Ann. §11-9-106(a): “Any person or entity who willfully and knowingly makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Compensation Commission.”