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Complete the P P R O V I D E R, C A R R I E R, Testimaging results, Treatment Plan including services, I hereby certify that this, Signature of Health Care Provider, Faxed, Emailed, to the CarrierSelf Insured, SECTION RESPONSE OF CARRIERSELF, The requested Treatment or Testing, The requested Treatment or Testing, The requested Treatment or Testing, Not in accordance with Medical, and The request or a portion thereof fields with any content which may be demanded by the system.

In the C A R R I E R, Signature of CarrierSelf Insured, The prior denied or approved with, I hereby certify that this, p y, Emailed, day of month year, day Printed Name, Faxed, Emailed, to the Health Care Provider and, Signature of CarrierSelf Insured, and Printed Name area, focus on the essential data.

The Form A is required to be filled, The requested Treatment or Testing, I hereby certify that this First, Signature of CarrierSelf Insured, Faxed, Emailed, to the Health Care Provider on, I hereby certify that a response, Signature of Health Care Provider, Faxed, to the CarrierSelf Insured, Emailed, day of day month year Printed, SECTION SUSPENSION OF PRIOR, and Suspension of Prior Authorization area enables you to point out the rights and responsibilities of either side.

End by looking at the following fields and filling them in as required: I hereby certify that this form, I hereby certify that this Appeal, Faxed, to the CarrierSelf Insured, Signature of Health Care Provider, Printed Name, SECTION DETERMINATION OF MEDICAL, The required information of LACC, The required information of LACC, I hereby certify that a written, Signature, Faxed, to the Health Care Provider, Emailed, and day of month year.

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Question	Answer
Form Name	LWC Form 1010
Form Length	2 pages
Fillable?	Yes
Fillable fields	94
Avg. time to fill out	19 min 22 sec
Other names	wcomp 1010 form, worker comp 1010 form, louisiana 1010 form, lwc 1010 form

P	Last Name:	First:		Middle:	Street Address, City, State, Zip:
A
T
T	Last 4 Digits of Social Security Number:		Date of Birth:		Phone Number:		Date of Injury:
I
E
N	Employers Name:			Street Address, City, State, Zip:				Phone Number:
T
C	Name:			Adjuster:			Claim Number	(if known):
A
R
R
I	Street Address, City, State Zip:			Email Address:		Phone Number:		Fax Number:
E
R
		SECTION 2. REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider
	Requesting Health Care Provider:				Phone Number:		Fax Number:
P
P	Street Address, City, State Zip:					Email:
R
O
V	Diagnosis:				CPT/DRG Code:		ICD/DSM Code:
I
D
E	Requested Treatment or Testing (Attach Supplement If Needed):
R

	Reason for Treatment or Testing (Attach Supplement If Needed):

Faxed	to the Carrier/Self Insured Employer on this the
I hereby certify that this completed form and above required information was	_____	day of ______ ,	______
Emailed	(day)	(month)	(year)
Signature of Health Care Provider:	Printed Name:

I hereby certify that this response of Carrier/Self Insured Employer for Authorization was		modification) on this the
		_____	day of ______ ,	______
	Emailed	(day)	(month)	(year)
Signature of Carrier/Self Insured Employer or Utilization Review Company:		Printed Name:


The prior denied or approved with modification request is now approved

	Faxed	to the Health Care Provider and Attorney of Claimant


		if one exists on this the
I hereby certify that this response of Carrier/Self Insured Employer for Authorization was		_____	day of ______ ,	______
	Emailed	(day)	(month)	(year)
	Emailed

Signature of Carrier/Self Insured Employer or Utilization Review Company:		Printed Name:

C	The requested Treatment or Testing is delayed because minimum information required by rule was not provided
A
A		Faxed	to the Health Care Provider on this the
R		Faxed	to the Health Care Provider on this the
R	I hereby certify that this First Request and accompanying Form 1010A was		_____	day of ______ ,	______
R			_____	day of ______ ,	______
I		Emailed	(day)	(month)	(year)
E	Signature of Carrier/Self Insured Employer or Utilization Review Company:
R

P		Faxed	to the Carrier/Self Insured Employer on this the
R	I hereby certify that a response to the First Request and	Faxed	to the Carrier/Self Insured Employer on this the
R
O			_____	day of ______ ,	______
O	accompanying Form 1010A was
V	accompanying Form 1010A was
V		Emailed	(day)	(month)	(year)
I		Emailed	(day)	(month)	(year)
D	Signature of Health Care Provider:		Printed Name:
E
R

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	Suspension of Prior Authorization Process due to Lack of Information
C
A	The requested Treatment or Testing is delayed due to a Suspension of Prior Authorization Due to Lack of Information
R
R
R	Faxed	to the Health Care Provider on this the
I	Faxed	to the Health Care Provider on this the
I	I hereby certify that this Suspension of Prior Authorization was	_____ day of	______ ,	______
E		_____ day of	______ ,	______
R	Emailed	(day)	(month)	(year)
	Signature of Carrier/Self Insured Employer or Utilization Review Company:	Printed Name:

	Appeal of Suspension to Medical Services Section by Health Care Provider
P
OR	I hereby certify that this form and all information previously submitted to Carrier/Self Insured Employer
	was faxed to OWCA Medical Services (Fax Number: 225-342-9836 this _______ day of ______, _________.
V
I
I	Faxed to the Carrier/Self Insured Employer on this the
D	Faxed to the Carrier/Self Insured Employer on this the
E	I hereby certify that this Appeal of Suspension of Prior Authorization was	_____ day of	______ ,	______
R	Emailed	(day)	(month)	(year)
	Signature of Health Care Provider:	Printed Name:

Faxed	to the Health Care Provider & Carrier/Self
Faxed	Insured Employer on this the
I hereby certify that a written determination was	Insured Employer on this the
I hereby certify that a written determination was	_____	day of ______ ,	______
	_____	day of ______ ,	______
Emailed	(day)	(month)	(year)
Signature:	Printed Name:

I hereby certify that additional information, pursuant to the determination of
Medical Services Section, was	Emailed	_____	day of ______ ,	______
		(day)	(month)	(year)
Signature of Health Care Provider:		Printed Name: