WCB Authorization NumberSTATE OF NEW YORK WORKERS COMPENSATION BOARD18007812362PROVIDERS REQUEST FOR JUDGMENT OF AWARDThisformmaybeusedbyanauthorizedworkerscompensationproviderwheneveracarrierors ID: 883056
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1 Mail completed form to: Workers' Compens
Mail completed form to: Workers' Compensation Board WCB Authorization NumberSTATE OF NEW YORK - WORKERS' COMPENSATION BOARD1-800-781-2362 PROVIDER'S REQUEST FOR JUDGMENT OF AWARD Thisformmaybeusedbyanauthorizedworkers'compensationproviderwheneveracarrierorself-insuredemployerhasnotpaidforanawardordecision(forawards/decisionsmadeonorafterMarch13,2007).Section54-bofWorkers'CompensationLawprovidesthatintheeventaninsurancecarrierorself-insuredemployerdefaultsinthepaymentofanawardmadebytheBoard,anypartytoanawardmay,withtheChair'sconsent(ortheconsentoftheChair'sdesignee),filewiththeCountyClerkforthecountyinwhichtheinjuryoccurredorthecountyinwhichthecarrierorself-insuredemployerhasitsprincipalplaceofbusiness,acertifiedcopyoftheUponissuanceofanadministrativeawardand/orarbitrationdecisionyoumustwaitatleast30daysbeforerequestingconsentforjudgment.Toavoidthecomplicationsoffilingunnecessaryrequests,waiting60daysisrecommended.The60daytimeperiodwill Name and Address of Health Care Provider Address CityStateZip Code- IstatethatIamachiropractor,authorizedhospitalrepresentative,physicaloroccupationaltherapist,podiatristorpsychologist,authorizedbylawtopracticeintheStateofNewYorkand/orauthorizedtorepresentahospital,amnotapartytothisproceeding,amtheproviderorrepresentativeofahospitalnotremuneratedfortheaboveaward(s)ordecision(s),havereadandknowthecontentsthereof;thatthesameistruetomyknowledge,exceptastothemattersstatedtobeoninformationandbelief,andasto IMPORTANT: BY LAW THOSE COMPLETING THIS SECTION MUST BE SWORN TO BEFORE A NOTARY PUBLIC. WCB Case Number Carrier/Self-InsuredEmployer I.D. Number Carrier Case Number Date of Accident or Injury Employer Request for Consent and Certified Copy of Unpaid Award or Decision for Medical CareName and Address of Carrier/Self-Insured Employer That(s)heisthe_________________________,dulylicensedintheStateofNewYorkand/orauthorizedtorepresentahospital,whohasnotbeenremuneratedfortheaboveaward(s)ordecision(s),andthat(s)hehasreadthesameandknowsthecontentsthereof;thatthesameistruetothe Name 1 2 Address Name 1 2 CityStateZip Code- County in Which Injury Occurredwww.wcb. IstatethatIamaphysician,authorizedbylawtopracticeintheStateofNewYork,amnotapartytothisproceeding,amthephysiciannotremuneratedfortheaboveaward(s)ordecision(s),havereadandknowthecontentsthereof;thatthesameistruetomyknowledge,exceptastothemattersstatedtobeoninformationandbelief,andastothosemattersIbelieveittobetrue. PHYSICIANS COMPLETE THE FOLLOWING: Affirmation of Non-Payment ALL OTHERS COMPLETE THE FOLLOWING: Mail completed form to: Workers' Compensation Board WCB Authorization NumberSTATE OF NEW YORK - WORKERS' COMPENSATION BOARD1-800-781-2362 PROVIDER'S REQUEST FOR JUDGMENT OF AWARD Thisformmaybeusedbyanauthorizedworkers'compensationproviderwheneveracarrierorself-insuredemployerhasnotpaidforanawardordecision(forawards/decisionsmadeonorafterMarch13,2007).Section54-bofWorkers'CompensationLawprovidesthatintheeventaninsurancecarrierorself-insuredemployerdefaultsinthepaymentofanawardmadebytheBoard,anypartytoanawardmay,withtheChair'sconsent(ortheconsentoftheChair'sdesignee),filewiththeCountyClerkforthecountyinwhichtheinjuryoccurredorthecountyinwhichthecarrierorself-insuredemployerhasitsprincipalplaceofbusiness,acertifiedcopyoftheUponissuanceofanadministrativeawardand/orarbitrationdecisionyoumustwaitatleast30daysbeforerequestingconsentforjudgment.Toavoidthecomplicationsoffilingunnecessaryrequests,waiting60daysisrecommended.The60daytimeperiodwill Name and Address of Health Care Provider Address CityStateZip Code- IstatethatIamachiropractor,authorizedhospitalrepresentative,physicaloroccupationaltherapist,podiatristorpsychologist,authorizedbylawtopracticeintheStateofNewYorkand/orauthorizedtorepresentahospital,amnotapartytothisproceeding,amtheproviderorrepresentativeofahospitalnotremuneratedfortheaboveaward(s)ordecision(s),havereadandknowthecontentsthereof;thatthesameistruetomyknowledge,exceptastothemattersstatedtobeoninformationandbelief,andasto IMPORTANT: BY LAW THOSE COMPLETING THIS SECTION MUST BE SWORN TO BEFORE A NOTARY PUBLIC. WCB Case Number Carrier/Self-InsuredEmployer I.D. Number Carrier Case Number Date of Accident or Injury Employer Request for Consent and Certified Copy of Unpaid Award or Decision for Medical CareName and Address of Carrier/Self-Insured Employer That(s)heisthe_________________________,dulylicensedintheStateofNewYorkand/orauthorizedtorepresentahospital,whohasnotbeenremuneratedfortheaboveaward(s)ordecision(s),andthat(s)hehasreadthesameandknowsthecontentsthereof;thatthesameistruetothe Name 1 2 Address Name 1 2 CityStateZip Code- County in Which Injury Occurredwww.wcb. IstatethatIamaphysician,authorizedbylawtopracticeintheStateofNewYork,amnotapartytothisproceeding,amthephysiciannotremuneratedfortheaboveaward(s)ordecision(s),havereadandknowthecontentsthereof;thatthesameistruetomyknowledge,exceptastothemattersstatedtobeoninformationandbelief,andastothosemattersIbelieveittobetrue. PHYSICIANS COMPLETE THE FOLLOWING: Affirmation of Non-Payment ALL OTHERS COMPLETE THE FOLLOWING: