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Get NY HP-1 2020-2024

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 Name of Claimant First Middle Initial Last Name I affirm under penalty of perjury that the conditions indicated above are true. Date HP-1 Page 1 of 2 8-14 Osteopathic WCB Authorization Number Podiatry Health Provider s Signature SECTION A REQUEST FOR ADMINISTRATIVE AWARD - PLEASE COMPLETE THE FOLLOWING Federal Tax ID Number SSN Total Charge Amount Paid Amount in Dispute EIN Any arbitration involving 1 000 or less is handled by desk arbitration using a single arbitrator Desk. If you have any questions regarding the completion of this form you may contact us at 1-800-781-2362. A. The fee s billed is in accordance with the fees indicated in the appropriate Fee Schedule AND B. NO related Denial of Claim or C-8. 1 has been received or if such form was received the issue s raised thereon by the workers compensation carrier has been ruled on by the Workers Compensation Board in the health provider s favor and no RB-89 is pending AND C. FOR ADMINISTRATIVE AWARD Treatment was rendered to an injured worker and a medical bill was timely submitted to the responsible insurance carrier or self-insured employer for payment. A minimum of 45 days has elapsed since the submission of the bill or 30 days since the date of a final decision by the WCB establishing the carrier s or self-insurer s liability for the bill and no more than 120 days have elapsed since the expiration of the time within which the carrier or self-insurer is required to notify the health provider of non-payment or since the date of expiration of any continuous course of treatment of the claimant. The provider has not received payment or an acceptable written explanation of non-payment as defined by the WCB from the responsible carrier. Communication with the insurer has been unsuccessful OR D. FOR ARBITRATION Treatment was rendered to an injured worker and a medical bill s was timely submitted to the responsible insurance carrier or self-insured employer for payment. Proper payment in accordance with the appropriate Fee Schedule has NOT been received* The provider has received a written explanation from the carrier or self-insured employer explaining reason s for partial or non-payment and Form C-8.

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