The Louisiana Request of Authorization/Carrier or Self Insured Employer Response — Form 1010 is a document used by employers or carriers in the state of Louisiana to respond to requests for authorization of treatment for an accident or illness. The form is used to verify the identity of the requesting party, the coverage of the requested medical treatment and the amount of benefits available. There are two types of Form 1010: the Carrier Response and the Self Insured Employer Response. The Carrier Response is used when a third-party carrier is providing insurance coverage for the employee. The Self Insured Employer Response is used when the employer is providing its own coverage. The form includes sections for the employer or carrier to provide contact information, the policy number, the date of the accident or illness, the name of the doctor or facility providing treatment, the type of treatment and the amount of benefits available. It also includes a section for the employer or carrier to sign off on the request.
Louisiana Request of authorization/carrier or self insured employer response - Form 1010
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How to fill out Louisiana Request Of Authorization/carrier Or Self Insured Employer Response - Form 1010?
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