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How to fill out the Form 26i online
Filling out the Form 26i is an essential step for medical providers seeking payment for services provided in a workers’ compensation claim. This guide offers a clear, step-by-step approach to help you complete this form correctly and efficiently.
Follow the steps to complete the Form 26i online.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- In Section A, provide medical provider information including the contact name, date(s) of service, address, total charges for services provided, telephone number, city, state, zip code, fax number, and email address.
- Indicate the status of the employer by checking the appropriate box for whether the employer is insured, self-insured, or uninsured.
- In Section B, enter the employee or claimant's details including their name, IC file number, address, home telephone number, social security number, sex, date of birth, and zip code.
- In Section C, provide the employer/carrier information such as the employer’s name, address, insurance carrier, policy number, work telephone number, and the carrier’s address and contact information.
- Section D requires the employer or carrier to respond regarding the claim's liability. Check the appropriate box indicating if they are not the employer or carrier, deny liability, or admit liability for the claim.
- If liability is admitted, indicate whether the employer or carrier accepts liability for the attached medical expenses by checking 'Yes' or 'No'.
- Provide an explanation if liability has been denied for either the claim or the attached medical expenses.
- Indicate if either party has requested a hearing before the Industrial Commission or if a compromise settlement agreement has been approved, along with the approval date.
- Finally, have the appropriate individual sign the form, ensuring to print their name and date it.
- After completing all sections, you can save the changes, download, print, or share the filled Form 26i as needed.
Start completing your Form 26i online now to ensure prompt processing of your medical claims.
Filing Form 26B online involves using the Income Tax Department's e-filing portal. First, register or log in to your account, then access the forms section. Follow the instructions to fill out and submit Form 26B accurately. If you need assistance, platforms such as uslegalforms can guide you through the online filing process with ease.
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