Health care providers shall complete and submit the appropriate HCFA billing form and needed documentation to the employer.
Insurer: if the employer is covered by an insurer, the appropriate billing form and documentation is to be sent to the insurer.
Signature: forms must be signed or typed with the name of the provider. Name and signature (if signature is used) must match.
Follow-up visits: bills for follow-up visits should include progress/office notes to support the diagnosis and codes billed.
Payment: the employer/insurer shall not be liable to pay for treatment until the required documents have been provided.
| Question | Answer |
|---|---|
| Form Name | LIBC-9 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 13 |
| Avg. time to fill out | 3 min |
| Edition | 09-22 |
| Where to send | The employer or insurer, according to the instructions on the form |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | LIBC-9, LIBC9, LIBC 9, LIBC-9 form, Workers' Compensation Medical Report Form |
| Official source | LIBC-9 (Rev 09-22), Pennsylvania Department of Labor and Industry |
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