Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 3 - Hearing Rules › Chapter 66 - Miscellaneous › Subchapter E - Forms › Section I-6633 - Stop Payment Form ; Form LDOL-WC-1003

Current through Register Vol. 50, No. 6, June 20, 2024
MAIL TO:
________________
-
______________
-________
OFFICE OF WORKERS' COMPENSATION SOCIAL SECURITY
								  NUMBER
POST OFFICE BOX 94040
BATON ROUGE, LA 70807 -9040
- _____________ - _______
(225) 342-7565, TOLL FREE (800) 201-3457 DATE OF
								  INJURY/ILLNESS
STOP PAYMENT FORM
This form is sent by the Employer/Insurer to the
								  injured worker and the OWC within 30 days of the closure of a case.
An
AMENDED COPY
is required if the
								  case re-opens or additional costs are incurred.
1.
								  __________________________________________________________________________________________
								  2. __________________ - _ - ________
(Employee) (Date of Birth) Date of this Notice
3.
								  __________________________________________________________________________________________
								  4. __________________ - ______________ - ________
Part(s) of Body Injured Date Compensation Paid
								  Through
5. Purpose of Form: (check one)
[] Payment stopped-Employee working at equal or
								  greater wage [] Payment stopped-Maximum period for paying SEB has expired
[] Payment stopped-Employee able to work at same
								  or greater wage [] Payment stopped-3rd Party recovery without notice
[] Payment stopped-Lump sum/Compromise
								  settlement approved [] Amend or correct prior 1003
[] Other
								  _______________________________________________
6. Length of Disability ____________________
								  weeks ____________________________ days.
7. Give
ICD - 9
Diagnostic
								  code(s)______________________________________________________________________ .
8. Give
CPT
Procedure code(s)
								  .
_____________________________________________________________________________________________________________________
9. COSTS INCURRED FOR THIS CASE:
A. Indemnity Benefits
1. Temporary total ....................... $ D.
								  Rehabilitation Expenses
2. Supplemental earnings
								  ..............____________________________________ 1. Medical rehabilitation
								  ....................$_________________
3. Permanent partial ..................... 2.
								  Vocational rehabilitation .................._________________
4. Permanent total ........................ 3.
								  Labor Market Survey ......................._________________
5. Death benefits ........................... 4.
								  Evaluation........................................._________________
6. Other benefits .......................... 5.
								  Other................................................_________________
TOTAL INDEMNITY
								  BENEFITS......________________________________________ TOTAL REHABILITATION
								  EPENSES........_________________
(Add A. items 1-6) (Add D. Items 1-5)
B. TOTAL SETTLEMENT AMOUNT
								  $_______________________
C. Medical Expenses E. TOTAL FUNERAL
								  EXPENSES..........$_____________
1. Hospital
								  ..................................
$
2. Physician ..................................
								  F. Legal Expenses
3. Diagnostic Tests/Procedures.... 1. Attorney
								  Fees ...............................
$ ______________
4. Prescription
								  Drugs.....................____________________________________ 2. Court Costs
								  ................................... ______________
5. Transportation
								  Costs..................____________________________________ 3. Deposition Costs
								  .......................... ______________ _
6. Independent Medical Exams..... 4.
								  Investigation Costs........................ ___________ ___
7. Occupational/Physical
								  Therapy._____________________________________ 5. Penalties and Interest
								  ...................
____________ ___
8.
								  Other............................................. 6. Administrative/Other
								  Costs............ _____________ __
TOTAL MEDICAL EXPENSES............ TOTAL LEGAL
								  EXPENSES ....................... ________________
(Add C. Items 1-8) (Add E. Items 1-5)
G. 3RD PARTY RECOVERIES FOR COSTS
								  ..........
$
(NOT INCLUDED ABOVE)
H. TOTAL WORKERS' COMPENSATION COSTS $
(Add A - G)
I . BALANCE OF UNUSED
								  RESERVES..................
$
Submitted by:
Preparer's Name:
								  ____________________________________________________________________
Employer/Insurer:
								  ____________________________________________________________________
Address:
Phone: ()
Employer/Insurer NCCI Number:
								  ______________________________________________
Phone:
()
Employer/Insurer NCCI
								  Number:__________________________
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1310.1.