Fill and Sign the How to Fill Out a Request for Payment Forservicee or Form

Form 114KENTUCKY DEPARTMENT OF WORKERS CLAIMS Frankfort, Kentucky 40601 REQUEST FOR PAYMENT FOR SERVICES OR REIMBURSEMENTFOR COMPENSABLE EXPENSESTO BE FILED WITH THE RESPONSIBLE EMPLOYER OR ITS PAYMENT OBLIGOR âName, address and Workers Compensation claim number of Employee for whom services were provided or expenses incurred: __________________________ ________________ ãSpecific type and dates of service(s) provided: Date(s)Type of Service(s) äName and address of physician who ordered services: (include written authorization if available) _________________ åReasonable value of services, including method of computation: $___: __ __________________ æOther expenses incurred for cure or relief of a work injury or occupational disease(s): DateDescription of Expense(s)$ AmountIf mileage, no. of miles - - - - - - - -- -- - - - --- --- - - - ---- ---- - Total $:Miles: Please attach receipts for all purchased items. Certification:I hereby certify that the above services were performed or expenses were incurred for the cure or relief of a work injury or occupational disease sustained by the above employee. Witness: _______________ (Name of Person requesting payment) Date: __________Address: __________ Phone no: _____________ NOTICE:Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.