When must I send the notice?

Send the Notice as soon as you identify an eligible reimbursement and within any contractually specified timeframe; missing contractual deadlines may forfeit recovery rights and limit appeals.

What attachments are required?

Include invoices, receipts, signed contracts, and any authorization documents. Attachments should be clearly referenced and numbered to speed payer verification and reduce follow-up requests.

Can I sign electronically?

Yes; electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention are demonstrable.

What if the payer denies my claim?

Review the denial reason, gather additional evidence if requested, and follow appeal procedures in the contract or program rules, noting any appeal deadlines to preserve rights.

Is notarization ever required?

Notarization depends on contract terms or state law; if a notary or witness is required, follow the state-specific rules for authentication or remote online notarization where permitted.

How long should I keep records?

Retain notices and supporting records at least as long as applicable federal or state retention rules require, commonly three years for tax-related items and six years for HIPAA-covered records.

Electronic Signature
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Notice of Intention to Claim Reimbursement

Notice of Intention to Claim Reimbursement

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Permanent Total Disability Agreement

(Effective Only for Dates of Injuries Prior to 10/01/1995)

PRINT IN INK or TYPE YOUR RESPONSES
ALL DATES MUST BE ENTERED in MM/DD/YYYY

Mail or fax completed copy to:

Department of Labor and Industry
Special Compensation Fund
PO Box 64229
St. Paul, MN 55164-0229
(651) 284-5045 or 1-800-342-5354
Fax: (651) 284-5731

DO NOT USE THIS SPACE

WID or SSN

Date of Injury

Employee Name

Employee Address

City

State

Zip Code

Insurer/Self-Insurer

Employer Name

Insurer Address

Insurer Claim Number

City

State

Zip Code

1. Attach any medical reports pertinent to the issue of permanent total disability whether pro or con, that have not been previously filed with the Workers’ Compensation Division. The parties are relying primarily upon medical reports by:

Health Care Provider(s)

Date of report(s)

2. The status of rehabilitation:

Continuing Closed Not assigned

3. Total disability benefits have been paid to the employee without substantial interruption since the proposed date of permanent total disability.

Yes No

4. Date the employee began receiving government disability benefits or government old age benefits:

Date

5. The employee is receiving or will receive supplementary benefits after an offset for government disability benefits or government old age benefits is taken.

Yes No

6. Has the issue of permanent total disability for the time period proposed been determined in a judicial or administrative proceeding?

Yes No

7. Will the offset provision of M.S. § 176.101, subd. 4 result in an overpayment of benefits to the employee?

Yes No

If yes, explain why there is an overpayment, the amount, and how it will be recovered.

WEEKLY BENEFIT CHANGE ANALYSIS

Proposed Effective Dates:

Before $25,000

Before PTD Date

TTD SSDI SB Subtotal OPC TOTAL

As of PTD Date

PTD SSDI SB Subtotal OPC TOTAL

After $25,000

SB NOT Payable

PTD SSDI SB Subtotal OPC TOTAL

When SB Payable

PTD SSDI SB Subtotal OPC TOTAL

*enter “F” for full benefit, “R” for reduced benefit

Workers’ compensation benefits must be coordinated with most government benefits. When a person is receiving more than one form of benefit, either the government benefit or the workers’ compensation benefit may be reduced. If you are not currently receiving government benefits, your workers’ compensation benefits may be affected in the future. After a specific waiting period, supplementary benefits will be paid, if necessary, to assure the employee’s compensation benefits are not less than 65% of the state-wide average weekly wage. If you have questions call Claims Services and Investigations.

KEY

PTD - permanent total disability

SB - supplementary benefits

SSDI - social security disability income; include old age, PERA, etc.

TTD - temporary total disability

OPC - overpayment credit

Agreement

Based on the information provided, the insurer/employer and employee agree that the employee’s total disability is permanent as of for purposes of the employer/insurer obtaining reimbursement of supplementary benefits under Minn. Rules 5222.0100 to 5222.1000.

All parties understand that a substantial error in the information on this form may be basis to vacate the agreement.

Employee Signature

Phone

Date

Employee Attorney Signature (If applicable)

Phone

Date

Claim Representative Signature

Phone

Date

Workers’ Compensation Division Signature

Approved Rejected

Phone

Date

Reason rejected:

What the Notice of Intention to Claim Reimbursement Is

A Notice of Intention to Claim Reimbursement is a formal written notification delivered to a payer, agency, or program administrator that advises them you intend to seek repayment for costs or expenses incurred. It identifies the claimant, describes the expense or overpayment, states the amount requested, cites legal or contractual grounds, and lists supporting documentation. The notice creates an official record that can trigger administrative review, preserve appeal rights, and set deadlines for responses. Electronic execution is generally permitted under ESIGN (15 U.S.C. ch. 96) and state UETA laws where applicable.

Why a Clear Notice Matters

Issuing a timely, complete Notice of Intention to Claim Reimbursement documents the claim, starts formal review, preserves appeal rights, and reduces processing delays for repayment or credit adjustments.

Who Typically Prepares This Notice

The Notice is used by organizations and individuals who need to document and pursue reimbursement under contracts, grants, insurance policies, or government programs.

Healthcare providers and clinics pursuing payer or program reimbursement for billed services.
Contractors and suppliers seeking contract-based cost recovery or corrected payments.
Grant recipients or subrecipients requesting reimbursement under award terms and conditions.

Tailor the notice format to the recipient's process and any contract or statutory requirements to avoid delays or rejection.

Step-by-Step: Completing the Notice

Follow a short sequence to prepare, deliver, and track a Notice of Intention to Claim Reimbursement for predictable results.

01

Gather Records: Collect invoices, contracts, receipts, and authorization documents.
02

Complete Notice: Fill claimant details, dates, amounts, and calculation lines carefully.
03

Submit to Payer: Send by certified mail, portal upload, or eSubmission per recipient rules.
04

Track Response: Log receipt, due dates, any clarifying requests, and outcome.

Typical Submission Workflow

A simple, repeatable workflow reduces errors and preserves an auditable trail for reimbursement claims.

Prepare Notice: Draft notice using required contract or program language.
Attach Evidence: Include invoices and other supporting files as referenced.
Send Notice: Deliver using the payer's accepted channel and retain proof.
Receive Acknowledgement: Capture any receipt confirmation and next-step guidance.

Configuring an Electronic Submission Workflow

Key settings help automate routing, secure the record, and notify stakeholders during electronic submission.

Field	Configuration
Signer Authentication	Email link, SMS code, or stronger KBA as required
Document Format	Use PDF/A or DOCX to preserve layout and attachments
Conditional Fields	Enable for optional supporting documentation details
Notification Settings	Email alerts, internal assignee, and audit log entries

Digital Submission: Platform and File Requirements

Confirm the recipient's accepted formats, authentication expectations, and whether they accept electronic notices.

Integrations: Salesforce, NetSuite, or ERP connectors speed routing
File Formats: PDF, DOCX, and scanned images commonly accepted
Authentication: Email link, SMS code, or multi-factor options

Use platforms that maintain an audit trail and secure storage to support disputes and compliance reviews.

Common Deadlines and Response Expectations

Timelines depend on contract terms and program rules; confirm deadlines before submitting to avoid forfeiting rights.

Submission Deadline:

Submit within any contract or grant time windows to preserve eligibility

Payer Response Period:

Commonly 30–60 days for review and initial reply

Appeal Deadline:

Typically 30 days after denial; check governing agreement

Statute Limits:

State limitations vary; some use 3–6 year limitation windows

Record Retention:

Retain copies until appeal windows and audits expire

Key Milestones in a Reimbursement Claim

Track these milestones from initial notice to final resolution to maintain legal protections and timely follow-up.

01

Draft and Review

Prepare full notice and verify supporting evidence before sending

02

Send and Record

Deliver notice using verifiable method and log confirmation

03

Payer Assessment

Payer reviews documents and may request clarification

04

Resolution or Appeal

Accept resolution or file appeal per recipient rules

What a Professional Notice Includes

A complete notice is structured and concise so reviewers can verify facts quickly and process payment or adjustment.

Header & ID

A clear title, reference number, and contract or claim identifier to tie the notice to contractual records for fast lookup.

Claimant Details

Full legal name, mailing address, and taxpayer identification to ensure payments route correctly and match vendor records.

Claim Summary

A short narrative describing the basis for reimbursement, including dates, locations, and applicable contract or policy paragraphs.

Calculation

Line-by-line math showing how the amount was determined, with references to invoice IDs and dates for auditability.

Attachments

A numbered list of invoices, receipts, time records, and authorizing documents attached and referenced in the notice.

Signature & Auth

Printed name, signature block, and signer title; include notarization or witness details if contractually required.

Security and Compliance Essentials for Electronic Notices

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Audit Trail: Time-stamped events and IP address capture

HIPAA Support: BAA available for protected health information

Regulatory Standards: ESIGN and UETA legal framework compliance

21 CFR Part 11: Controls for FDA-regulated records

Certifications: SOC 2 Type II and ISO 27001 available

Penalties and Risks of an Incorrect Notice

Claim Denial: Payer may reject incomplete notices

Late Forfeiture: Missed deadlines can forfeit recovery rights

Tax Impact: Incorrect reporting can trigger IRS issues

Fraud Allegations: Misstated amounts risk fraud investigations

Appeal Loss: Insufficient records weaken appeals

Privacy Exposure: Improper handling may violate privacy laws

Common Mistakes to Avoid

Missing or inconsistent claimant identification that prevents matching to existing vendor or contract records.
Submitting amounts without clear invoice references or calculations, creating avoidable back-and-forth with the payer.
Failing to follow the recipient's specified submission channel, resulting in processing delays or misplaced notices.
Using inadequate signer authentication or lacking required consent disclosures for consumer-facing notices under ESIGN.

How This Notice Compares with a Demand Letter

Compare the Notice of Intention to Claim Reimbursement with a demand letter to choose the correct document for your objective.

Criteria	Notice	Demand Letter
Formality	administrative/formal	negotiation/collection
Notarization	sometimes required	rarely required
Typical Use	trigger review and recovery	request payment or settlement
Legal Effect	creates administrative record	supports negotiation or litigation

eSignature Platform Pricing Snapshot for Filing Notices

Platform pricing and feature availability affect cost and compliance; signNow is listed first for comparison with common competitors.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card required	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (Business Premium tier)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA available)	Yes	Yes	No	No
Envelope Cap	No envelope cap	100 envelopes/user/year cap	Varies	Varies	Varies

Frequently Asked Questions About the Notice

Answers to common questions help avoid procedural errors, clarify eSignature validity, and explain next steps after submission.

Need help? Contact support

When must I send the notice?
Send the Notice as soon as you identify an eligible reimbursement and within any contractually specified timeframe; missing contractual deadlines may forfeit recovery rights and limit appeals.
What attachments are required?
Include invoices, receipts, signed contracts, and any authorization documents. Attachments should be clearly referenced and numbered to speed payer verification and reduce follow-up requests.
Can I sign electronically?
Yes; electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention are demonstrable.
What if the payer denies my claim?
Review the denial reason, gather additional evidence if requested, and follow appeal procedures in the contract or program rules, noting any appeal deadlines to preserve rights.
Is notarization ever required?
Notarization depends on contract terms or state law; if a notary or witness is required, follow the state-specific rules for authentication or remote online notarization where permitted.
How long should I keep records?
Retain notices and supporting records at least as long as applicable federal or state retention rules require, commonly three years for tax-related items and six years for HIPAA-covered records.

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