Form WC-381 "Medical Provider Application for Payment or Reimbursement of Medical Payment" - New Jersey

What Is Form WC-381?

This is a legal form that was released by the New Jersey Department of Labor & Workforce Development - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 26, 2015;
  • The latest edition provided by the New Jersey Department of Labor & Workforce Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WC-381 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Labor & Workforce Development.

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Download Form WC-381 "Medical Provider Application for Payment or Reimbursement of Medical Payment" - New Jersey

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MEDICAL PROVIDER APPLICATION FOR
State of New Jersey
CASE NO’S.: ___________________________
Department of Labor and Workforce Development
PAYMENT OR REIMBURSEMENT OF
Division of Workers’ Compensation
MEDICAL PAYMENT
VICINAGE:
___________________________
PO Box 381
Trenton, NJ 08625-0381
**please enter above only if filing an Amended Claim**
NEW FILING
AMENDED FILING
WC-381 r. 8/26/2015
TAX IDENTIFICATION NUMBER:
TAX IDENTIFICATION NUMBER:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER:
TELEPHONE NUMBER :
FAX NUMBER:
vs
NAME:
NAME :
IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE BELOW:
ADDRESS:
ADDRESS:
CARRIER CLAIM NUMBER:
INDICATE THE STATUS OF THE EMPLOYER:
INSURED
UNINSURED
SELF-INSURED (PRIVATE)
SELF-INSURED (GOVT. AGENCY.)
IF UNINSURED, INDIVIDUAL CORPORATE OFFICERS ARE ALSO NAMED AS
Note:
RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS.
Corporations must be represented by counsel in
Workers’ Compensation Proceedings
SOCIAL SECURITY NUMBER:
SSN Not Available
NAME:
ADDRESS:
The injured worker
has
has not filed a Workers’ Compensation Claim
Petition related to this injury.
Claim Petition #:
DATE OF BIRTH:
SEX:
TO THE DIVISION OF WORKERS’ COMPENSATION
Applicant, alleging that the Employee sustained an injury by an accident arising out of and in the course of his / her employment with Respondent,
compensable under R.S. 34:15-7 et seq., supplements and amendments, respectfully states:
Date of Accident or Injury(required):
Date of Last Treatment:
Occupational Exposure
Occupation:
Diagnosis:
History of Accident or Illness:
Date(s) of Treatment:
Date Billed:
Amount Billed:
Amount Paid:
1.
2.
3.
4.
See attached for additional treatment
MEDICAL PROVIDER APPLICATION FOR
State of New Jersey
CASE NO’S.: ___________________________
Department of Labor and Workforce Development
PAYMENT OR REIMBURSEMENT OF
Division of Workers’ Compensation
MEDICAL PAYMENT
VICINAGE:
___________________________
PO Box 381
Trenton, NJ 08625-0381
**please enter above only if filing an Amended Claim**
NEW FILING
AMENDED FILING
WC-381 r. 8/26/2015
TAX IDENTIFICATION NUMBER:
TAX IDENTIFICATION NUMBER:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER:
TELEPHONE NUMBER :
FAX NUMBER:
vs
NAME:
NAME :
IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE BELOW:
ADDRESS:
ADDRESS:
CARRIER CLAIM NUMBER:
INDICATE THE STATUS OF THE EMPLOYER:
INSURED
UNINSURED
SELF-INSURED (PRIVATE)
SELF-INSURED (GOVT. AGENCY.)
IF UNINSURED, INDIVIDUAL CORPORATE OFFICERS ARE ALSO NAMED AS
Note:
RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS.
Corporations must be represented by counsel in
Workers’ Compensation Proceedings
SOCIAL SECURITY NUMBER:
SSN Not Available
NAME:
ADDRESS:
The injured worker
has
has not filed a Workers’ Compensation Claim
Petition related to this injury.
Claim Petition #:
DATE OF BIRTH:
SEX:
TO THE DIVISION OF WORKERS’ COMPENSATION
Applicant, alleging that the Employee sustained an injury by an accident arising out of and in the course of his / her employment with Respondent,
compensable under R.S. 34:15-7 et seq., supplements and amendments, respectfully states:
Date of Accident or Injury(required):
Date of Last Treatment:
Occupational Exposure
Occupation:
Diagnosis:
History of Accident or Illness:
Date(s) of Treatment:
Date Billed:
Amount Billed:
Amount Paid:
1.
2.
3.
4.
See attached for additional treatment
What other facts are there that you believe important?
Summary of Changes (Complete only if filing an Amended pleading):
The Applicant therefore requests that the Division of Workers’ Compensation determine the amount of payment due from said
Respondent, under Revised Statutes of New Jersey, Title 34, Chapter 15, and the acts supplemental thereto and amendatory thereof,
and that your Applicant may be awarded costs in this proceeding, and such other or further relief as may be proper.
Applicant
STATE OF NEW JERSEY
COUNTY OF ________________________
Subscribed and sworn or affirmed
to before me this _______ day of __________________ , 20_____
____________________________________________
This Application has been presented by the service provider to the Division of Workers’ Compensation for hearing and determination.
Unless an Answer is filed within 30 days of the date of service of the Applicant upon you, with the assignment clerk at the vicinage to
which the claim is assigned as indicated on the reverse side, and a copy served upon the attorney, THE APPLICANT WILL PROCEED
WITH PROOF OF CLAIM ACCORDING TO LAW AND MAY OBTAIN JUDGMENT AGAINST YOU.
The Privacy Act, 5 U.S.C. §552a, the Social Security Act, 42 U.S.C. §405, and N.J.S.A. 34:15-1 et seq. authorize the Division of
Workers’ Compensation to request that the Applicant supply the Division with the employee’s Social Security number for record keeping
purposes and cross-matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any
other proper public purpose.
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