Louisiana Workers Compensation Forms

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Louisiana Workers Compensation Forms – Form 1002 Notice of Payment

This is one of the first Louisiana workers compensation forms sent to the injured worker when the first workers compensation indemnity check is sent. It also has to be mailed out when the amount if the check is changed or benefits are being stopped. The purpose of the form is to show the claimant the numbers used to come up with the weekly check. It also has to be sent before indemnity checks are stopped. It was set up by a law passed by the Louisiana State Legislature to create a “safe harbor” for employers who calculate your benefits wrong. If there is a disagreement about the amounts or termination the injured worker should send in the Notice of Disagreement. The adjuster will have five days to correct any mistakes or request a hearing with the workers compensation judge. If they don’t they may have to pay penalties and attorney fees if the amount if the check was wrong or if they had no reason to stop your workers compensation benefits.


Louisiana Workers Compensation Forms – Form 1003 Stop Payment

This form has to be sent to the injured employee and the Louisiana Office of Workers Compensation within thirty days of a case being closed. It is used by the Louisiana Workforce Commission to keep track of the cost and expense related to claims for workers compensation.


Louisiana Workers Compensation Forms – Form 1004 Request for Social Security Information

This form is used by an employer to request information about whether an injured worker is receiving Social Security disability benefits. By law, if in certain situations if someone is permanently disabled under workers compensation and gets Social Security, the workers compensation checks may be decreased.


Louisiana Workers Compensation Forms – Forms 1005A and 1005B Social Security Offset

These are the Louisiana workers compensation forms that are used when an injured employee’s workers compensation benefits are going to be reduced because he or she also gets Social Security benefits.


Louisiana Workers Compensation Forms – Form 1006 Subpoena

These Louisiana workers compensation forms are used to subpoena someone to come to the Louisiana Office of Workers Compensation District Office to give testimony. Workers compensation cases are similar to lawsuits in the Louisiana District Courts. Testimony is taken and evidence produced to prove someone is or isn’t too hurt to work. Just like in civil or criminal court a person can be subpoenaed to appear. If they don’t they can be held in contempt of court.


Louisiana Workers Compensation Forms – LWC-WC IA-1 (former 1007) First Report of Injury

There are a number of Louisiana workers compensation forms the insurance company has to file. This is the First Report of Injury your employer has to send in to its workers compensation insurer. The insurer then reports the information to the Louisiana Office of Workers Compensation. This form should have all of the basic information about your accident and injury. Ask for a copy.


Louisiana Workers Compensation Forms – Form 1008 Disputed Claim for Compensation

This is one of the most frequent Louisiana workers compensation forms used to put your claim in front of the Louisiana Office of Workers Compensation district office when a dispute comes up. The issue will be decided by an administrative hearing officer who essentially has all of the power and authority of a state court judge. Some of the common reasons we’ll file a 1008 for you are:
• No wage benefits have been paid;
• No medical treatment has been authorized;
• Your checks are not the right amount;
• Your check was improperly reduced or stopped;
• You are denied medical treatment you need;
• You are denied the opportunity to see the doctor you chose;
• You are disabled and unable to work; and,
• You have not received the vocational rehabilitation you’re entitled to.


Louisiana Workers Compensation Forms – Form 1009 Disputed Claim for Medical Treatment

Called a Disputed Claim for Medical Treatment, this form is filed when there is a dispute between the injured worker and the employer about medical treatment. This form follows another one of the Louisiana workers compensation forms that are common – the Form 1010 which is sent in by your doctor to the claims adjuster. The Form 1010 requests authorization for medical treatment. The Form 1009 is sent to the Medical Director at the Louisiana Office of Workers Compensation who gives an opinion about the treatment being disputed. Once the Medical Director has weighed in the party that doesn’t agree can file a Form 1008. The Form 1009 can only be filed if the insurer has denied a request for medical treatment, has modified the request somehow, or has not acted on a request. An injured worker can also file the Form 1009 if the treatment requested isn’t addressed in the Louisiana Workers Compensation Medical Guidelines.


Louisiana Workers Compensation Forms – Form 1010 Request for Medical Treatment

Any healthcare provider who wants to give an injured worker any treatment which will cost more than $750 has to file the Form 1010 along with all supporting medical records. For instance, if your doctor wants to send you to physical therapy he or she needs to fill out the form, explain why the physical therapy is needed and also send his or her medical notes to the adjuster. If your doctor doesn’t fill the Form 1010 out the right way or doesn’t give the records that support the request it will be delayed or denied.


Louisiana Workers Compensation Forms – Form 1011 Request for Lump Sum Settlement

The Louisiana Office of Workers Compensation has to approve any final settlement of an entire claim for benefits. This means you can’t just settle your case forever and give up your right for future medical treatment and indemnity (wage) checks. If you settle your whole claim the insurer will have its attorney draft the settlement documents that go with this form. You will have to sign a release that outlines the terms. You may also have to have a Medicare Set-Aside Arrangement set up. These are legally binding documents. If you want to settle your case, please contact Mitchell & Associates for help.


Louisiana Workers Compensation Forms – Form 1015 Request for Independent Medical Examination

This form is filled out by the party that wants to have an Independent Medical Examination (IME) done. This comes up when there is a dispute about your medical condition between the doctor you selected and the doctor your employer picked to provide a second medical opinion (SMO). The vast majority of the time it is the employer that makes the request. The Director of the Louisiana Office of Workers Compensation selects the doctor to try to act as the tie breaker. Regardless of what the IME says you’re still entitled to your day in court if you’re benefits are going to be stopped.


Louisiana Workers Compensation Forms – Form 1020 Employee’s Monthly Report of Earnings

If after you’re hurt on the job you can return to work with restrictions on what you can and can’t do you may still be entitled to get weekly checks. If you can work, but you can’t make more than 90% of what you made before your accident you should get supplemental earnings benefits (SEB). You may be required to turn in the Form 1020 every month to the claims adjuster to show what you made that month. If you get to the point where you’re making 90% of what you did before you’re workers compensation checks may be stopped.


Louisiana Workers Compensation Forms – Form WC 1121 Choice of Physician Form

This is the form you fill out to select your doctor. Under the Louisiana Workers Compensation Act you are entitled to be treated by a doctor you chose. However, once you pick a doctor it is very difficult to change to another doctor in the same field or specialty. You can be referred to a specialist. If so your employer will be responsible for paying both doctors. For example – if you chose to be treated by Dr. Smith, an orthopedist, and want to start seeing another orthopedist you may not be able to. But if Dr. Smith refers you to Dr. Jones, a neurologist, workers comp will cover both doctors. Make sure you do not pick the company doctor to be your doctor. If you do it will be very difficult to switch.

Sending us information about your potential case does not mean we will automatically represent you – you are telling us about your situation in order for us to evaluate whether we believe you have a case which we may choose to handle on your behalf. We will review your circumstances and let you know as soon as possible whether we can discuss your potential case with you further. The information you give us is confidential and can’t be shared with anyone outside of our office.