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Form 1010 is an IRS form used to request a refund of the excise tax on heavy trucks, buses, and trailers.

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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.

Question	Answer
Form Name	Form 1010
Form Length	2 pages
Fillable?	Yes
Fillable fields	106
Avg. time to fill out	21 min 46 sec
Other names	printable 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
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
	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
		to the Health Care Provider and Attorney of Claimant
				if one exists		on this the
				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)
			(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				_____	day of ______ ,	______
I			Emailed	(day)	(month)	(year)

ESignature of Carrier/Self Insured Employer or Utilization Review Company:

P		Faxed	to the Carrier/Self Insured Employer on this the
P
R	I hereby certify that a response to the First Request and
R
O
O	accompanying Form 1010A was		_____	day of ______ ,	______
V	accompanying Form 1010A was		_____	day of ______ ,	______
V			(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
A
R
R
R
			Faxed	to the Health Care Provider on this the

I
I	I hereby certify that this Suspension of Prior Authorization was			_____ day of	______ ,	______
E				_____ day of	______ ,	______
R			Emailed	(day)	(month)	(year)
R


	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)
R


	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
		to the Health Care Provider & Carrier/Self
		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)
	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 ______ ,	______
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.

Complete the P, PROVIDER Physical, Findings, Clinical, Tests Test, imaging, results Signature, of, HealthCare, Provider Faxed, Emailed, day, of, day, month, year, Printed, Name and Other, Attach, brief, explanation fields with any content which may be demanded by the system.

In the CARRIER, Faxed, modification, on, this, the day, of, month, year day, Emailed, Printed, Name Faxed, Emailed, if, one, exists, on, this, the day, of, day, of, day, month, year and Printed, Name area, focus on the essential data.

The Faxed, to, the, HealthCare, Provider, on, this, the Emailed, day, of, day, month, year accompanying, Form, A, was Signature, of, HealthCare, Provider Faxed, day, of Emailed, day, month, year, Printed, Name Faxed, to, the, HealthCare, Provider, on, this, the day, of Emailed, and day, month, year, Printed, Name 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: day, month, year, Printed, Name Faxed, day, of, Emailed, day, month, year Signature, of, HealthCare, Provider Printed, Name Signature, Faxed, Emailed, to, the, HealthCare, Provider, Carrier, Self Insured, Employer, on, this, the day, of, month, year dayPrinted, Name Medical, Services, Section, was Emailed, and day, of

part 5 to entering details in lwc 1010 form

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Form 1010 – Fill Out and Use This PDF

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