Fill and Sign the Supreme Court Rhode Island Courts Rigov Form

Page 1 of 2 Rev 02/15 W.C.C. Pending Petitions: __________________________ __________________________ State of Rhode Island and Providence Plantations Providence, S c. Workers’ Compensation C ourt W.C.C. # ___ ___ ________________ __ Health Care Provider: Employee to whom services were furnished : ___________________________________ ___________________________________ Health Care Provider -Petitioner Patient Name ___________________________________ __________________________ _________ Address Address XXX -XX -V- Social Security Number (last four digits only ) Employer: Insurance Carrier: ___________________________________ ___________________________________ Employer Name Insurer Name _________________________ __________ ___________________________________ Address Address Agent for Service of Process (if a corporation or partnership) : ___________________________________ Agent of Service Name ___________________________________ Address Petition For An Order Concerning Payment For Medical Services The petitioner requests an order for the payment of medical or related services, as defined in the Workers’ Compensation Act, which were furnished by the petit ioner to the above named injured employee, and in support of this petition states: 1. The above named employer is liable for the payment of such medical and related services by reason of an agreement or decree concerning compensation. A copy of said agreement or decree establishing such liability is attached hereto. Page 2 of 2 Rev 02/15 \ W.C.C. ______________________ 2. The services furnished were necessary in order to cure, rehabilitate or relieve said employee from the effect of an injury which was sustained on (Date of Injury) __________________or from the effect of an occupational disease which caused disablement on said date. 3. The petitioner has complied with all requirements of the Workers’ Compensation Act concerning notice, reports, bills , and permission for surgery, if applicable , pursuant to R.I .G .L . § 28- 33-5 through § 28- 33-10. 4. An itemized bill and corresponding reports in triplicate , showing dates, C.P.T. codes , nature of services, charges, and credits for any payme nts received, is filed herewith, pursuant to R .I .G .L . § 28 -33- 8 (f)(1). 5. That twenty -one (21) days have passed since request for payment upon the employer or insurer or wr itten notice to the employer or insurer of their failure to fulfill the obligation pursuant to R .I.G.L. § 28 -33-8. ____________________________________________ Name of Attorney for Petitioner ____________________________________________ ________ ____________________________________ Attorney Address & Phone Number Petitioner ____________________________________________ ____________________________________________ Bar Registration Number Date