Form 1010 Request of Authorization/Carrier or Self Insured Employer Response

Form 1010 is a U.S. Department of Labor - issued form also known as the "Request Of Authorization/carrier Or Self Insured Employer Response".

A PDF of the latest Form 1010 can be downloaded below or found on the U.S. Department of Labor Forms and Publications website.

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LWC FORM 1010 - REQUEST OF AUTHORIZATION/CARRIER OR SELF INSURED EMPLOYER RESPONSE
PLEASE PRINT OR TYPE
SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care Provider
Last Name:
First:
Middle:
Street Address, City, State, Zip:
P
A
T
Last 4 Digits of Social Security Number:
Date of Birth:
Phone Number:
Date of Injury:
I
E
Employers Name:
Street Address, City, State, Zip:
Phone Number:
N
T
C
Name:
Adjuster:
Claim Number (if known):
A
R
R
Street Address, City, State Zip:
Email Address:
Phone Number:
Fax Number:
I
E
R
SECTION 2. REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider
Requesting Health Care Provider:
Phone Number:
Fax Number:
P
Street Address, City, State Zip:
Email:
R
O
V
Diagnosis:
CPT/DRG Code:
ICD/DSM Code:
I
D
E
Requested Treatment or Testing (Attach Supplement If Needed):
R
Reason for Treatment or Testing (Attach Supplement If Needed):
INFORMATION REQUIRED BY RULE TO BE INCLUDED WITH REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider
(Following is the required minimum information for Request of Authorization (LAC 40:2715 (C))
History provided to the level of condition and as provided by Medical Treatment Schedule
Physical Findings/Clinical Tests
P
P
Documented functional improvements from prior treatment
R
O
Test/imaging results
V
I
Treatment Plan including services being requested along with the frequency and duration
D
Faxed
to the Carrier/Self Insured Employer on this the
E
R
I hereby certify that this completed form and above required information was
_____ day of ______ , ______
Emailed
(day)
(month)
(year)
Signature of Health Care Provider:
Printed Name:
SECTION 3. RESPONSE OF CARRIER/SELF INSURED EMPLOYER FOR AUTHORIZATION
(Check appropriate box below and return to requesting Health Care Provider, Claimant and Claimant Attorney as provided by rule)
The requested Treatment or Testing is approved
The requested Treatment or Testing is approved with modifications
(Attach summary of reasons and explanation of any modifications)
The requested Treatment or Testing is denied because
Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons)
The request, or a portion thereof, is not related to the on-the-job injury
The claim is being denied as non-compensable
Other (Attach brief explanation)
Faxed
to the Health Care Provider (and to the Attorney of
C
A
Claimant if one exists, if denied or approved with
R
modification) on this the
I hereby certify that this response of Carrier/Self Insured Employer for Authorization was
R
_____ day of ______ , ______
I
(day)
(month)
(year)
Emailed
E
R
Signature of Carrier/Self Insured Employer or Utilization Review Company:
Printed Name:
The prior denied or approved with modification request is now approved
to the Health Care Provider and Attorney of Claimant
Faxed
if one exists on this the
I hereby certify that this response of Carrier/Self Insured Employer for Authorization was
y
y
p
p y
_____ day of ______ , ______
_____ day of ______ , ______
(day)
(month)
(year)
Emailed
Signature of Carrier/Self Insured Employer or Utilization Review Company:
Printed Name:
LWC FORM 1010 - REQUEST OF AUTHORIZATION/CARRIER OR SELF INSURED EMPLOYER RESPONSE
PLEASE PRINT OR TYPE
SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care Provider
Last Name:
First:
Middle:
Street Address, City, State, Zip:
P
A
T
Last 4 Digits of Social Security Number:
Date of Birth:
Phone Number:
Date of Injury:
I
E
Employers Name:
Street Address, City, State, Zip:
Phone Number:
N
T
C
Name:
Adjuster:
Claim Number (if known):
A
R
R
Street Address, City, State Zip:
Email Address:
Phone Number:
Fax Number:
I
E
R
SECTION 2. REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider
Requesting Health Care Provider:
Phone Number:
Fax Number:
P
Street Address, City, State Zip:
Email:
R
O
V
Diagnosis:
CPT/DRG Code:
ICD/DSM Code:
I
D
E
Requested Treatment or Testing (Attach Supplement If Needed):
R
Reason for Treatment or Testing (Attach Supplement If Needed):
INFORMATION REQUIRED BY RULE TO BE INCLUDED WITH REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider
(Following is the required minimum information for Request of Authorization (LAC 40:2715 (C))
History provided to the level of condition and as provided by Medical Treatment Schedule
Physical Findings/Clinical Tests
P
P
Documented functional improvements from prior treatment
R
O
Test/imaging results
V
I
Treatment Plan including services being requested along with the frequency and duration
D
Faxed
to the Carrier/Self Insured Employer on this the
E
R
I hereby certify that this completed form and above required information was
_____ day of ______ , ______
Emailed
(day)
(month)
(year)
Signature of Health Care Provider:
Printed Name:
SECTION 3. RESPONSE OF CARRIER/SELF INSURED EMPLOYER FOR AUTHORIZATION
(Check appropriate box below and return to requesting Health Care Provider, Claimant and Claimant Attorney as provided by rule)
The requested Treatment or Testing is approved
The requested Treatment or Testing is approved with modifications
(Attach summary of reasons and explanation of any modifications)
The requested Treatment or Testing is denied because
Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons)
The request, or a portion thereof, is not related to the on-the-job injury
The claim is being denied as non-compensable
Other (Attach brief explanation)
Faxed
to the Health Care Provider (and to the Attorney of
C
A
Claimant if one exists, if denied or approved with
R
modification) on this the
I hereby certify that this response of Carrier/Self Insured Employer for Authorization was
R
_____ day of ______ , ______
I
(day)
(month)
(year)
Emailed
E
R
Signature of Carrier/Self Insured Employer or Utilization Review Company:
Printed Name:
The prior denied or approved with modification request is now approved
to the Health Care Provider and Attorney of Claimant
Faxed
if one exists on this the
I hereby certify that this response of Carrier/Self Insured Employer for Authorization was
y
y
p
p y
_____ day of ______ , ______
_____ day of ______ , ______
(day)
(month)
(year)
Emailed
Signature of Carrier/Self Insured Employer or Utilization Review Company:
Printed Name:
SECTION 4. FIRST REQUEST
(Form 1010A is required to be filled out by Carrier/Self Insured Employer and Health Care Provider)
The requested Treatment or Testing is delayed because minimum information required by rule was not provided
C
A
to the Health Care Provider on this the
Faxed
R
I hereby certify that this First Request and accompanying Form 1010A was
_____ day of ______ , ______
R
(day)
(month)
(year)
I
Emailed
E
Signature of Carrier/Self Insured Employer or Utilization Review Company:
R
P
Faxed
to the Carrier/Self Insured Employer on this the
R
I hereby certify that a response to the First Request and
O
_____ day of ______ , ______
accompanying Form 1010A was
V
Emailed
(day)
(month)
(year)
I
D
Signature of Health Care Provider:
Printed Name:
E
R
SECTION 5. SUSPENSION OF PRIOR AUTHORIZATION DUE TO LACK OF INFORMATION
Suspension of Prior Authorization Process due to Lack of Information
C
A
The requested Treatment or Testing is delayed due to a Suspension of Prior Authorization Due to Lack of Information
R
R
to the Health Care Provider on this the
Faxed
I
_____ day of ______ , ______
I hereby certify that this Suspension of Prior Authorization was
E
R
(day)
(month)
(year)
Emailed
Signature of Carrier/Self Insured Employer or Utilization Review Company:
Printed Name:
Appeal of Suspension to Medical Services Section by Health Care Provider
P
R
I hereby certify that this form and all information previously submitted to Carrier/Self Insured Employer
O
was faxed to OWCA Medical Services (Fax Number: 225-342-9836 this _______ day of
______, _________.
V
V
I
Faxed
to the Carrier/Self Insured Employer on this the
D
I hereby certify that this Appeal of Suspension of Prior Authorization was
_____ day of ______ , ______
E
R
Emailed
(day)
(month)
(year)
Signature of Health Care Provider:
Printed Name:
SECTION 6. DETERMINATION OF MEDICAL SERVICES SECTION
The required information of LAC40:2715(C) was not provided
The required information of LAC40:2715(C) was provided
O
to the Health Care Provider & Carrier/Self
Faxed
W
Insured Employer on this the
C
I hereby certify that a written determination was
A
_____ day of ______ , ______
(day)
(month)
(year)
Emailed
Signature:
Printed Name:
SECTION 7. HEALTH CARE PROVIDER RESPONSE TO MEDICAL SERVICES DETERMINATION
P
Faxed
to the Carrier/Self Insured Employer on this the
R
I hereby certify that additional information, pursuant to the determination of
O
Medical Services Section, was
_____ day of ______ , ______
V
Emailed
I
(day)
(month)
(year)
D
Signature of Health Care Provider:
Printed Name:
E
R

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