Form 1010 PDF Details

Form 1010 is the most common form for estate tax returns. This form is used by estates that have a gross value of over $5,430,000. If you are required to file a Form 1010, there are a few things you need to know in order to make the process as smooth as possible. In this blog post, we will discuss what you need to know about Form 1010, including how to complete it and when it needs to be filed. We will also provide some tips for making the process easier.

If you want to first determine how much time you will need to prepare the form 1010 and what number of pages it's got, here's some basic information that could be helpful.

QuestionAnswer
Form NameForm 1010
Form Length2 pages
Fillable?Yes
Fillable fields106
Avg. time to fill out21 min 46 sec
Other namesprintable 1010 form online pdf, 1010form, lwc form 1010, 1010 form la

Form Preview Example

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

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

P R O V I D E R

Requesting Health Care Provider:

Phone Number:

Fax Number:

 

 

 

 

Street Address, City, State Zip:

 

Email:

 

 

 

 

 

Diagnosis:

CPT/DRG Code:

ICD-9/DMS-4 Code:

 

 

 

 

Requested Treatment or Testing (Attach Supplement If Needed):

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

I

 

 

 

 

Emailed

(day)

(month)

(year)

ESignature 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

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

accompanying Form 1010A was

 

 

 

 

_____

day of ______ ,

______

V

 

 

 

 

 

 

 

 

 

(day)

(month)

(year)

I

 

 

 

 

Emailed

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Faxed

to the Health Care Provider on this the

 

 

 

 

 

I

 

 

 

 

 

I hereby certify that this Suspension of Prior Authorization was

_____ day of

______ ,

______

E

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Faxed

to the Carrier/Self Insured Employer on this the

D

 

 

 

 

 

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

 

 

 

 

 

 

 

 

Insured Employer on this the

I hereby certify that a written determination was

_____

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 Form 1010 Online for Free

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Step 1: Locate the button "Get Form Here" and then click it.

Step 2: As soon as you have accessed your 1010 work comp form edit page, you'll discover all functions you may use regarding your file in the top menu.

Provide the data demanded by the application to prepare the form.

step 1 to filling in lwc 1010 form

Complete the PPROVIDER, PhysicalFindingsClinicalTests, Testimagingresults, SignatureofHealthCareProvider, Faxed, Emailed, dayofdaymonthyearPrintedName, and OtherAttachbriefexplanation fields with any content which may be demanded by the system.

Finishing lwc 1010 form step 2

In the CARRIER, Faxed, modificationonthisthe, dayofmonthyear, day, Emailed, PrintedName, Faxed, Emailed, ifoneexistsonthisthe, dayofdayofdaymonthyear, and PrintedName area, focus on the essential data.

part 3 to completing lwc 1010 form

The Faxed, totheHealthCareProvideronthisthe, Emailed, dayofdaymonthyear, accompanyingFormAwas, SignatureofHealthCareProvider, Faxed, dayof, Emailed, daymonthyearPrintedName, Faxed, totheHealthCareProvideronthisthe, dayof, Emailed, and daymonthyearPrintedName area enables you to point out the rights and responsibilities of either side.

Filling out lwc 1010 form stage 4

End by looking at the following fields and filling them in as required: daymonthyearPrintedName, Faxed, dayofEmaileddaymonthyear, SignatureofHealthCareProvider, PrintedName, Signature, Faxed, Emailed, totheHealthCareProviderCarrierSelf, InsuredEmployeronthisthe, dayofmonthyear, dayPrintedName, MedicalServicesSectionwas, Emailed, and dayof.

part 5 to entering details in lwc 1010 form

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