Get NC Form 18M 2017-2023

NC. GOV/DOCFILING.HTML FORM 18M 10/2017 PAGE 1 OF 1 EMPLOYEE FILING OPTIONS E-MAIL TO EXECSEC IC. NC. North Carolina Industrial Commission IC File EMPLOYEE S APPLICATION FOR ADDITIONAL MEDICAL COMPENSATION G*S* 97-25. 1 Emp* Code Carrier Code APPLICABLE TO INJURIES BY ACCIDENT OR OCCUPATIONAL DISEASES CONTRACTED ON OR AFTER 5 JULY 1994 Employer FEIN The Use of This Form Is Required Under the Provisions of the Workers Compensation Act. Employee s Name Address Employer s Address City State Home Telephone Last 4 Digits of SSN Sex Telephone Number Zip Insurance Carrier Work Telephone M F XXX-XX- / Date of Birth Carrier s Address Carrier s Telephone Number Fax Number SECTION A. TO BE COMPLETED BY EMPLOYEE The above-named employee claims additional medical compensation as a result of an injury by accident or an occupational disease which occurred on or by Date because Reason for Additional Medical Compensation Additional medical and/or other supporting documentation is / is not attached optional. Place your I. C. File on each attachment. SIGNATURE OF EMPLOYEE DATE COMPLETED Name and address of employee s attorney if any EMPLOYEE SEND THE ORIGINAL OF THIS FORM AND ANY SUPPORTING DOCUMENTATION TO THE INDUSTRIAL COMMISSION AS INSTRUCTED AT THE BOTTOM OF THIS FORM AND SEND A COPY TO THE EMPLOYER OR CARRIER/ADMINISTRATOR* SECTION B. TREATING PHYSICIAN S STATEMENT OPTIONAL This is to certify that 1. I am the above-named employee s treating physician* My area of medical practice is and my treatment of the employee began on. mo/day/yr 2. In my opinion there is a substantial risk that the employee will need the following additional medical care or monitoring including medical surgical hospital nursing rehabilitation services medicines sick travel replacement of artificial members medical and surgical supplies and other treatment The need for this medical treatment results from the injury by accident or occupational disease as set forth in Section A. above. SIGNATURE OF TREATING PHYSICIAN PRINTED NAME ADDRESS CITY DATE STATE ZIP ATTORNEYS/CARRIERS FILE VIA ELECTRONIC DOCUMENT FILING PORTAL HTTP //WWW*IC. GOV FAX TO 919 715-0282 MAIL TO NCIC-EXECUTIVE SECRETARY 1236 MAIL SERVICE CENTER RALEIGH NC 27699-1236 HELPLINE 800 688-8349 WEBSITE HTTP //WWW*IC. North Carolina Industrial Commission IC File EMPLOYEE S APPLICATION FOR ADDITIONAL MEDICAL COMPENSATION G*S* 97-25. 1 Emp* Code Carrier Code APPLICABLE TO INJURIES BY ACCIDENT OR OCCUPATIONAL DISEASES CONTRACTED ON OR AFTER 5 JULY 1994 Employer FEIN The Use of This Form Is Required Under the Provisions of the Workers Compensation Act. 1 Emp* Code Carrier Code APPLICABLE TO INJURIES BY ACCIDENT OR OCCUPATIONAL DISEASES CONTRACTED ON OR AFTER 5 JULY 1994 Employer FEIN The Use of This Form Is Required Under the Provisions of the Workers Compensation Act. Employee s Name Address Employer s Address City State Home Telephone Last 4 Digits of SSN Sex Telephone Number Zip Insurance Carrier Work Telephone M F XXX-XX- / Date of Birth Carrier s Address Carrier s Telephone Number Fax Number SECTION A. .