LWC Form 1010 – Fill Out and Use This PDF

The LWC Form 1010 serves as a critical instrument for requesting authorization for medical treatments or testing by health care providers for workers' compensation cases. It facilitates communication between health care providers and insurance carriers or self-insured employers, ensuring that necessary medical services are approved and administered in a timely manner. To streamline the process of obtaining authorization for treatment or testing related to on-the-job injuries, submitting this form correctly is essential. For details on how to fill out the form accurately and efficiently, click the button below.

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Form 1010 PDF Details

The LWC Form 1010, or Request for Authorization/Carrier or Self Insured Employer Response, plays a critical role in the healthcare process for individuals filing claims related to workplace injuries or illnesses. At its core, this form serves as a communication tool between healthcare providers and insurance carriers or self-insured employers, ensuring that the necessary medical treatments or tests are authorized in a timely manner. It is meticulously designed with several sections, each requiring detailed information starting with identifying details of the patient, followed by the healthcare provider's request for authorization. It includes a comprehensive account of the treatment or testing needed, supported by diagnoses codes and reasons for the requested medical interventions. Furthermore, the form mandates the inclusion of a signed declaration by the healthcare provider, affirming that all required information is accurate and complete. On the flip side, responses from carriers or self-insured employers are critical, determining the approval, modification, or denial of the requested treatments or tests. Such responses are based on specific criteria, such as compliance with medical treatment schedules or relevance to the job-related injury, thereby setting a clear path for appeals or further actions if necessary. Moreover, it provides mechanisms for addressing delays or suspensions in authorization due to insufficient information, emphasizing the importance of complete and accurate documentation. The criticality of this form in managing the healthcare authorization process cannot be overstated, as it directly impacts the timely delivery of care to injured or ill workers.

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

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LWC FORM 1010 - REQUEST OF AUTHORIZATION/CARRIER OR SELF INSURED EMPLOYER RESPONSE

PLEASE PRINT OR TYPE

SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care Provider

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):

INFORMATION REQUIRED BY RULE TO BE INCLUDED WITH REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care Provider

(Following is the required minimum information for Request of Authorization (LAC 40:2715 (C))

P R O V I D E R

History provided to the level of condition and as provided by Medical Treatment Schedule

Physical Findings/Clinical Tests

Documented functional improvements from prior treatment

Test/imaging results

Treatment Plan including services being requested along with the frequency and duration

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:

SECTION 3. RESPONSE OF CARRIER/SELF INSURED EMPLOYER FOR AUTHORIZATION

(Check appropriate box below and return to requesting Health Care Provider, Claimant and Claimant Attorney as provided by rule)

C A R R I E R

The requested Treatment or Testing is approved

The requested Treatment or Testing is approved with modifications (Attach summary of reasons and explanation of any modifications)

The requested Treatment or Testing is denied because

Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons)

The request, or a portion thereof, is not related to the on-the-job injury

The claim is being denied as non-compensable

Other (Attach brief explanation)

Faxed to the Health Care Provider (and to the Attorney of

Claimant if one exists, if denied or approved with

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:

SECTION 4. FIRST REQUEST

(Form 1010A is required to be filled out by Carrier/Self Insured Employer and Health Care Provider)

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

SECTION 5. SUSPENSION OF PRIOR AUTHORIZATION DUE TO LACK OF INFORMATION

	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:

SECTION 6. DETERMINATION OF MEDICAL SERVICES SECTION

O W C A

The required information of LAC40:2715(C) was not provided

The required information of LAC40:2715(C) was provided

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:

SECTION 7. HEALTH CARE PROVIDER RESPONSE TO MEDICAL SERVICES DETERMINATION

P R O V I D E R

Faxed to the Carrier/Self Insured Employer on this the

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:

How to Edit LWC Form 1010 Online for Free

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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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LWC Form 1010 – Fill Out and Use This PDF

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