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What is an SI 12?

SI-12 (7/23) Affidavit docHubing That Compensation Has Been Secured. Employers with Board-approved self-insurance for workers compensation. Filed with the government agency issuing a permit, license, or contract. The SI-12 must be completed by the Boards Self-Insurance Office.

When a provider initially examines a workers compensation patient what document must be filed with the state?

(e)(1) Within 5 working days following initial examination, a primary treating physician shall submit a written report to the claims administrator on the form entitled Doctors First Report of Occupational Injury or Illness, Form 5021.

Which type of document is filled with the Workers Compensation Board to document any docHub change in the workers medical or disability status?

What report is filed? A detailed narrative progress/supplemental report to document any docHub change in the workers medical or disability status.

Which form is used to submit claims to workers compensation insurance quizlet?

The claim will be submitted on paper to the workers compensation payer on a CMS-1500 form.

When a provider initially examines a workers compensation patient what document must be filled with the state?

(e)(1) Within 5 working days following initial examination, a primary treating physician shall submit a written report to the claims administrator on the form entitled Doctors First Report of Occupational Injury or Illness, Form 5021.

What is a C 4 document?

Filing A Workers Compensation Claim The C-4 form is titled Employees Claim for Compensation/Report of Initial Treatment. The physician fills out their part of the form, and sends a copy to your employer and the insurer. Be sure to get a copy for your records.

What is a C 4 document?

Filing A Workers Compensation Claim The C-4 form is titled Employees Claim for Compensation/Report of Initial Treatment. The physician fills out their part of the form, and sends a copy to your employer and the insurer. Be sure to get a copy for your records.

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What is an SI 12?

When a provider initially examines a workers compensation patient what document must be filed with the state?

Which type of document is filled with the Workers Compensation Board to document any docHub change in the workers medical or disability status?

Which form is used to submit claims to workers compensation insurance quizlet?

When a provider initially examines a workers compensation patient what document must be filled with the state?

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What is a C 4 document?

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What is an SI 12?

When a provider initially examines a workers compensation patient what document must be filed with the state?

Which type of document is filled with the Workers Compensation Board to document any docHub change in the workers medical or disability status?

Which form is used to submit claims to workers compensation insurance quizlet?

When a provider initially examines a workers compensation patient what document must be filled with the state?

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