Required Medical Documentation. This section of the Medical Expense Certificate must be fully completed in order for your claim to be considered. Any corrections or additional information necessary to cure an incomplete Medical Expense Certificate must be submitted to NCSBT within two months of the expiration of the one-year deadline to file a claim. Provide all information required below regarding all medical expenses for which you are seeking reimbursement/payment (i.e., expenses not covered under the insurance, plans, or benefits programs identified above). You must provide updated, itemized medical provider statements which reflect date(s) of service, services rendered, International Classification of Diseases diagnostic codes (ICD-10 diagnostic codes), charges for services, payments, and any outstanding balances. You must also provide all applicable Explanation of Benefit statements. If additional space is needed, please list on a separate page and attach. “See attached” is not an acceptable response to this section: • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ I, , hereby certify that the information provided on this Medical Expense Certificate and the attached documentation represent all true, correct, current, and up-to-date information supporting this claim, and I have completed this form and provided such documentation to the best of my ability. This the day of , 20 . This form must be signed by the...
Required Medical Documentation. A physician’s statement as to the fitness of the employee for the performance of their duties may be required at any time before such leave commences, and may be required prior to the employee’s return to duty, and further, the Employer may request that the employee submit to a physical examination at the Employer’s expense by a physician of the Employer’s choice. Such physician shall be Board certified with the appropriate specialty providing such Board certified physician is reasonably available.
