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

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.

FAQ

Q: What is the Form WCB-190A?
A: The Form WCB-190A is the Provider's Petition for Payment of Medical and Related Services.

Q: What is the purpose of the Form WCB-190A?
A: The purpose of the Form WCB-190A is for medical providers to petition for payment of services provided to injured workers.

Q: Who can use the Form WCB-190A?
A: Medical providers in the state of Maine can use the Form WCB-190A.

Q: What information is required on the Form WCB-190A?
A: The Form WCB-190A requires information such as the injured worker's name, date of injury, description of services provided, and the amount being claimed.

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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.

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

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  • Form WCB-190A Providers Petition for Payment of Medical and Related Services - Maine, Page 1
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