How to fill out a request for payment forservicee or reimbursement for compenable expenses form 2025

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Form 114 is a document from the Kentucky Department of Workers Claims used to request payment for services or reimbursement for expenses related to work injuries or occupational diseases. It requires details about the employee, type and dates of services provided, physician information, reasonable value of services, other incurred expenses, and certification of the claim's validity. The form also includes a notice regarding fraudulent claims.

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