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Fill and Sign the Medical Treatment Statement for Workers Compensation Wisconsin Form

Fill and Sign the Medical Treatment Statement for Workers Compensation Wisconsin Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           MEDICAL TREATMENT STATEMENT Department of Workforce Development Worker's Compensation Division Room C100 P.O. Box 7901 SUPPLIES AND MEDICATIONS Madison, Wisconsin 53707-7901 Telephone: (608) 266-1340 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 Worker's Compensation Division and other parties to this case at least 15 days before the hearing according to section 1 02.1 7(8) of the statutes. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(l)(m)]. WC Claim Number Employee Name Employee Social Security Number Employer Name Injury Date Insurance Company Name Names of Providers of Treatment, Medication, or Supplies Total Amount Paid By Amount Paid By Other Insurance Carriers(Give Carriers' Names) Unpaid Charges Applicant Balance TOTAL: WKC-3 (R. 02/2000)

Valuable instructions for finalizing your ‘Medical Treatment Statement For Workers Compensation Wisconsin’ online

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