Fill and Sign the Kentucky Request Payment Form

Form 114 KENTUCKY DEPARTMENT OF WORKERS CLAIMS Frankfort, Kentucky 40601 REQUEST FOR PAYMENT FOR SERVICES OR REIMBURSEMENT FOR COMPENSABLE EXPENSES TO BE FILED WITH THE RESPONSIBLE EMPLOYER OR ITS PAYMENT OBLIGOR  Name, address and Workers Compensation claim number of Employee for whom services were provided or expenses incurred: ____________________________________________________________________________________________ ____________________________________________________________________________________________  Specifc type and dates of service(s) provided: Date(s) Type of Service(s)  Name and address of physician who ordered services: (include written authorization if available) ____________________________________________________________________________________________  Reasonable value of services, including method of computation: $_______________:_____________ ____________________________________________________________________________________________  Other expenses incurred for cure or relief of a work injury or occupational disease(s): Date Description of Expense(s) $ Amount If mileage, no. of miles - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Total $: Miles: Please attach receipts for all purchased items. Certifcation: 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 fles 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.