"Summary of Settlement of Medical Benefits" - Montana

Summary of Settlement of Medical Benefits is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on April 5, 2019;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

ADVERTISEMENT
ADVERTISEMENT

Download "Summary of Settlement of Medical Benefits" - Montana

Download PDF

Fill PDF online

Rate (4.6 / 5) 61 votes
EMPLOYMENT RELATIONS DIVISION
SUMMARY OF SETTLEMENT OF MEDICAL BENEFITS
Form must be completed in full
(1) CLAIMANT:
DATE OF PRIMARY INJURY:
INSURER’S PRIMARY CLAIM #:
ADDITIONAL DATE OF INJURY(S) #:
ACN #:
INSURER CLAIM(S) #
ADDITIONAL ACN #(S):
(Include all Claim #s)
DATE OF MAXIMUM MEDICAL IMPROVEMENT (MMI):
(2) Copy of last medical report(s) that documents MMI, diagnosis and recommendation for treatment.
(Please attach and list what the attachments are by date and document author.)
(3) Explanation of rationale used for the closure of medical benefits by settlement. Include the parties’
understanding of medical benefits related to the claim(s) being settled (attach extra page(s) if needed).
Dollar amount of medical benefits included in this settlement $
(4) The settlement of medical benefits is in the best interest of the parties because:
Claimant’s Explanation needs to be provided on this form: (attach extra page(s) if needed)
Claimant’s signature:
Acknowledgement of Claimant’s Best Interest Statement
Insurer’s Explanation needs to be provided on this form: (attach extra page(s) if needed)
(5) Claimant’s Signature:
Date:
Witness:
Date:
Insurer’s Signature:
Date:
(6) Claimant’s Attorney:
Fee: $
(Please Print Name)
(Do not include costs)
Attorney must provide an explanation of fees applied to the portion of the settlement representing medical
benefits obtained due to the efforts of the attorney.
(7) Reviewed By:
Date:
(ERD Examiner)
Questions concerning this form should be addressed to: Employment Relations Division, Claims Assistance Bureau,
PO Box 8011, Helena, MT 59604-8011, Phone (406) 444-6543
Revised 4/5/19
EMPLOYMENT RELATIONS DIVISION
SUMMARY OF SETTLEMENT OF MEDICAL BENEFITS
Form must be completed in full
(1) CLAIMANT:
DATE OF PRIMARY INJURY:
INSURER’S PRIMARY CLAIM #:
ADDITIONAL DATE OF INJURY(S) #:
ACN #:
INSURER CLAIM(S) #
ADDITIONAL ACN #(S):
(Include all Claim #s)
DATE OF MAXIMUM MEDICAL IMPROVEMENT (MMI):
(2) Copy of last medical report(s) that documents MMI, diagnosis and recommendation for treatment.
(Please attach and list what the attachments are by date and document author.)
(3) Explanation of rationale used for the closure of medical benefits by settlement. Include the parties’
understanding of medical benefits related to the claim(s) being settled (attach extra page(s) if needed).
Dollar amount of medical benefits included in this settlement $
(4) The settlement of medical benefits is in the best interest of the parties because:
Claimant’s Explanation needs to be provided on this form: (attach extra page(s) if needed)
Claimant’s signature:
Acknowledgement of Claimant’s Best Interest Statement
Insurer’s Explanation needs to be provided on this form: (attach extra page(s) if needed)
(5) Claimant’s Signature:
Date:
Witness:
Date:
Insurer’s Signature:
Date:
(6) Claimant’s Attorney:
Fee: $
(Please Print Name)
(Do not include costs)
Attorney must provide an explanation of fees applied to the portion of the settlement representing medical
benefits obtained due to the efforts of the attorney.
(7) Reviewed By:
Date:
(ERD Examiner)
Questions concerning this form should be addressed to: Employment Relations Division, Claims Assistance Bureau,
PO Box 8011, Helena, MT 59604-8011, Phone (406) 444-6543
Revised 4/5/19