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  • Ny Hp-1 2020

Get Ny Hp-1 2020-2025

HEALTH PROVIDER S REQUEST FOR DECISION ON UNPAID MEDICAL BILL S HP-1 Return this original and completed form with the required attachments to the Workers Compensation Board when the conditions listed below exist. WCB MUST ACCOMPANY EACH REQUEST. RETURN THIS ORIGINAL AND COMPLETED FORM TO NYS Workers Compensation Board PO Box 5205 Binghamton NY 13902-5205 Medical Director s Office/Finance 328 State Street Schenectady NY 12305-2318 NUMBER OF MEDICAL BILLS ATTACHED FEE SUBMITTED CHECK/M. O. NO. TYPE OF CARE Medical Outpatient Hospital Inpatient Name and Mailing Address of Health Provider MAXIMUM OF 30 CHARACTERS Name Address City State Chiropractic Physical Therapy Occupational Therapy WCB Case Number Psychology Provider s WCB Rating Code Date You First Treated Claimant mm/dd/yy Provider s Telephone Number include area code Date of Accident mm/dd/yy // Carrier Case Number Zip Code Carrier or Self-Insured Employer ID W County where Service was Rendered Claimant s Social Security Number Nam....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232