PROVIDER’S PETITION FOR PAYMENT OF MEDICAL
AND RELATED SERVICES, WCB-190A
A healthcare provider or their representative may file this petition
to request a determination of an injured employee’s entitlement
to payment of medical and related services arising from their work-related
injury.
Distribution
The Provider’s Petition for Payment of Medical and Related Services,
WCB-190A, 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 PROVIDER’S PETITION FOR
PAYMENT OF MEDICAL AND RELATED SERVICES, WCB-190A
Health Care Provider
Name
Enter the healthcare provider’s name.
Street/P.O. Box:
Enter the healthcare provider’s mailing address.
City, State, Zip:
Enter the city, state and zip code of the healthcare provider’s
mailing address.
Telephone Number
Enter the healthcare provider’s business telephone number, including
the area code.
Employee Name:
Enter the injured employee’s first name, middle initial and last
name.
Employee Social Security Number
Enter the injured employee’s social security number.
Date of Injury:
Enter the injured employee’s date of injury (month, day, year).
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.
- 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.
- The charges for medical
and related services in connection with this injury amount
to: $______________.
Attach Copies of All Bills
Enter the dollar value of all unpaid charges for medical and related
services arising from the aforementioned employee’s work-related
injury.
__________________________
Signature of Health Care Representative
This line must be signed by the healthcare provider or their representative.
Dated: ___/___/____
MM DD YYYY
Enter the date (month, day, year) that this form was signed by the healthcare
provider or their representative.
______________________________
Name of Employee’s Attorney or Advocate (If Any)
If the healthcare provider is represented by an attorney or advocate,
enter the name of the healthcare provider’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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