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Home >Board Forms> Petition for Payment of Medical and Related Services Instructions

PETITION FOR PAYMENT OF MEDICAL
AND RELATED SERVICES, WCB-190

An injured employee or their representative may file this petition to request a determination of the injured employee’s entitlement to payment of medical and related services arising from the work-related injury.

Distribution

The Petition for Payment of Medical and Related Services, WCB-190, is to be distributed as follows:

Original Mail the original petition to the Workers’ Compensation Board at the following address by regular mail:

State of Maine
Workers’ Compensation Board
27 State House Station
Augusta, Maine 04333-0027

Copy 1 Mail one copy of the petition by certified mail, return receipt requested to the insurance company or 3rd-party administrator (if there is an insurance company or 3rd-party administrator representing the employer).

Copy 2 Mail one copy of the petition by certified mail, return receipt requested to the employer.

Copy 3 Keep one copy of the petition for your records. Also keep the green certified mail cards (for the copies sent to the insurance company or 3rd‑party administrator and the employer) when the U.S. Post Office returns them to you.

INSTRUCTIONS FOR COMPLETING PETITION FOR PAYMENT
OF MEDICAL AND RELATED SERVICES, WCB-190

Employee

Name
Enter the injured employee’s first name, middle initial and last name.

Street/P.O. Box
Enter the injured employee’s mailing address.

City, State, Zip
Enter the city, state and zip code of the injured employee’s mailing address.

Telephone Number
Enter the injured employee’s home telephone number, including the area code.

Employee Social Security Number
Enter the injured employee’s social security number.

Board File Number
If you know the file number assigned by the Workers’ Compensation Board, enter it here.

Employer

Name
Enter the employer’s name.

Street/P.O. Box
Enter the employer’s mailing address.

City, State, Zip
Enter the city, state and zip code of the employer’s mailing address.

Insurance Company

Name
Enter the name of the insurance company or 3rd-party administrator (if there is one) who represents the employer’s interest in this workers’ compensation claim.

Street/P.O. Box
Enter the insurance company or 3rd-party administrator’s mailing address.

City, State, Zip
Enter the city, state and zip code of the insurance company or 3rd-party administrator’s mailing address.

  1. On ___/___/____, ________ experienced a work-related injury while working for ________.
    MM DD YYYY Employee Name Employer Name
    Enter the date (month, day, year) of the employee’s injury on the first line.
    Enter the injured employee’s name (first name, middle initial and last name) on the second line.
    Enter the employer’s name on the third line.
  2. Describe how the injury occurred:
    Enter a brief description of how the injury occurred.
  3. List body part(s) injured:
    Enter a list of the body parts affected by the injury or illness. When specifying a part of the body, be sure to indicate whether it is “left” or “right.” When the injury involves fingers or toes, use the numbers one through five to describe the body part. (One is the thumb or big toe; five is the little finger or little toe.)
  4. The charges for medical and related services such as prescriptions and mileage in connection with this injury amount to: $________________.
    Attach Copies of All Bills
    Enter the dollar value of all unpaid medical bills and related charges (prescription, mileage, etc.). Be sure to attach copies of all unpaid bills.

_________________________
Signature of Employee
This line must be signed by the injured employee or their representative.

Dated: ___/___/____
MM DD YYYY
Enter the date (month, day, year) that this form was signed by the injured employee or their representative.

______________________________
Name of Employee’s Attorney or Advocate (If Any)
If the injured employee is represented by an attorney or advocate, enter the name of the employee’s attorney or advocate.

______________________________
Street/P.O. Box
Enter the attorney or advocate’s mailing address.

______________________________
City, State, Zip
Enter the city, state and zip code of the attorney or advocate’s mailing address.

 

 

 

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