Form WCB-190A "Provider's Petition for Payment of Medical and Related Services" - Maine

What Is Form WCB-190A?

This is a legal form that was released by the Maine Workers' Compensation Board - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2015;
  • The latest edition provided by the Maine Workers' Compensation Board;
  • 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 fillable version of Form WCB-190A by clicking the link below or browse more documents and templates provided by the Maine Workers' Compensation Board.

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Download Form WCB-190A "Provider's Petition for Payment of Medical and Related Services" - Maine

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PROVIDER'S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES
STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0027
HEALTH CARE PROVIDER
EMPLOYER
NAME:
NAME:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
EMPLOYEE
INSURER
NAME:
NAME:
LAST FOUR DIGITS SSN: XXX-XX-
STREET/P.O. BOX:
DATE OF INJURY:
CITY, STATE, ZIP:
BOARD FILE NUMBER (if known):
NOTICE
When there is no ongoing dispute, if bills for medical or health care services are not paid within 30 days after the carrier has received notice
of nonpayment by certified mail from the provider of the medical or health care services or, if the bill was paid by the employee, from the
employee who paid for the medical or health care services, $50 or the amount of the bill due, whichever is less, must be added and paid to
the provider of the medical or health care services or, if the bill was paid by the employee, to the employee who paid for the medical or
health care services for each day over 30 days in which the bills for medical or health care services are not paid. Not more than $1,500 in
total may be added pursuant to this subsection.
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The treatment included
DESCRIBE THE TREATMENT PROVIDED
for the employee’s injured
.
LIST BODY PARTS INJURED
3. The charges related to the medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids
provided for treatment of the employee’s work-related injury or disease are as set forth on the attached bills (do not
attach statements).
THEREFORE, the provider asks the board to order benefits pursuant to Title 39 or 39-A.
__________________________________________________________
DATED:
SIGNATURE OF PETITIONER
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF PROVIDER’S ATTORNEY (IF ANY)
1.
Mail original petition to the Workers’ Compensation Board at the
above address by regular mail.
STREET/P.O. BOX
2.
Mail one (1) copy by certified mail, return receipt requested, to
each other party named in the petition.
CITY, STATE, ZIP
3.
Keep one (1) copy for yourself and keep the green certified mail
cards when returned to you by the U.S. Post Office.
TELEPHONE NUMBER
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon
request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine
Relay 711.
WCB-190A (eff. 10/1/15)
PROVIDER'S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES
STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0027
HEALTH CARE PROVIDER
EMPLOYER
NAME:
NAME:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
TELEPHONE NUMBER:
EMPLOYEE
INSURER
NAME:
NAME:
LAST FOUR DIGITS SSN: XXX-XX-
STREET/P.O. BOX:
DATE OF INJURY:
CITY, STATE, ZIP:
BOARD FILE NUMBER (if known):
NOTICE
When there is no ongoing dispute, if bills for medical or health care services are not paid within 30 days after the carrier has received notice
of nonpayment by certified mail from the provider of the medical or health care services or, if the bill was paid by the employee, from the
employee who paid for the medical or health care services, $50 or the amount of the bill due, whichever is less, must be added and paid to
the provider of the medical or health care services or, if the bill was paid by the employee, to the employee who paid for the medical or
health care services for each day over 30 days in which the bills for medical or health care services are not paid. Not more than $1,500 in
total may be added pursuant to this subsection.
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The treatment included
DESCRIBE THE TREATMENT PROVIDED
for the employee’s injured
.
LIST BODY PARTS INJURED
3. The charges related to the medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids
provided for treatment of the employee’s work-related injury or disease are as set forth on the attached bills (do not
attach statements).
THEREFORE, the provider asks the board to order benefits pursuant to Title 39 or 39-A.
__________________________________________________________
DATED:
SIGNATURE OF PETITIONER
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF PROVIDER’S ATTORNEY (IF ANY)
1.
Mail original petition to the Workers’ Compensation Board at the
above address by regular mail.
STREET/P.O. BOX
2.
Mail one (1) copy by certified mail, return receipt requested, to
each other party named in the petition.
CITY, STATE, ZIP
3.
Keep one (1) copy for yourself and keep the green certified mail
cards when returned to you by the U.S. Post Office.
TELEPHONE NUMBER
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon
request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine
Relay 711.
WCB-190A (eff. 10/1/15)