Hp 1 Form PDF Details

Are you looking for an easy way to keep track of your business expenses and other financial data? If so, then the HP 1 Form could be just what you need. This useful document can help simplify accounting processes by providing a standardized way to record essential information such as income, expenditures and deductions. In this blog post we'll take a look at how the HP 1 Form works, and why it's often used in businesses across Canada. Regardless of whether you're running a small side-hustle or managing numerous accounts for clients, understanding the importance of organizing your finances is key - and that's where the HP 1 Form comes in. Read on to find out more!

QuestionAnswer
Form NameHp 1 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshp1 form wcb, wc forms hp 1, provider request decision, hp1 form

Form Preview Example

REQUEST FOR DECISION ON UNPAID

MEDICAL BILL(S)

HP-1

Return this completed and signed form with the required attachments (listed under letter A) to the Workers' Compensation Board when the conditions listed below exist.

A.The medical bill(s) was submitted to the responsible insurance carrier or self-insured employer for payment on Form C-4, C-4.2, C-4.3, C-5, EC-4Narr, OT/PT-4, PS-4, CMS-1450 or CMS-1500 (with narrative) or UB-04; AND

B.The medical bill(s) was submitted to the responsible insurance carrier or self-insured employer for payment within 120 days from the day the service(s) was rendered. The medical bill(s) must contain all treatment rendered by a provider on a single day; AND

C.A minimum of 45 days has elapsed since the submission of the medical bill(s); AND

D.The provider has NOT received proper payment in accordance with the applicable Fee Schedule; AND

E. NO related Denial of Claim or Form C-8.1 [Notice of Treatment Issue(s)/Disputed Bill Issue(s)] has been received OR, if such form was received, a minimum of 30 days has elapsed since the date of a final decision by the WCB establishing the insurance carrier's or self- insured employer's liability for the bill and no RB-89 [Application for Board Review] is pending; AND

F. No more than 120 days has elapsed since the expiration of the time within which the insurance carrier or self-insured employer is required to notify the provider of partial or non-payment.

CHECK ONLY ONE REQUEST BOX: (PLEASE TYPE OR PRINT THIS FORM IN BLACK OR BLUE INK ONLY)

A. REQUEST FOR ADMINISTRATIVE AWARD

The provider did NOT receive Form C-8.4 [Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s)] or an acceptable written explanation of the reasons for partial or non-payment (as defined by the WCB);

AND

The medical bill was NOT for one of the following types of care: Ambulance, Audiology, Dental, Durable Medical Equipment, Laboratory, Optometry, Other, Out of State or Pharmacy.

NOTE: HP-1s for these types of care MUST be submitted to Arbitration, even if the insurance carrier or self-insured employer did not notify of an objection to the bill.

Submit this completed and signed form to the address below. A copy of the medical bill must be attached.

DO NOT SUBMIT MORE THAN ONE BILL WITH THIS FORM.

RETURN THIS COMPLETED AND SIGNED FORM TO:

NYS Workers' Compensation Board

PO Box 5205

Binghamton, NY 13902-5205

DATE SPAN FOR ATTACHED BILL: ______/______/______ TO ______/______/______

B. REQUEST FOR ARBITRATION

The provider has received Form C-8.4 [Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s)] or an acceptable written explanation of partial or non-payment (as defined by the WCB); communication with the insurance carrier or self-insured employer has failed to resolve the issue(s);

The medical bill(s) was for one of the care types on the reverse side of this form.

OR

If the bill(s) was for one of the following types of care: Ambulance, Audiology, Dental, Durable Medical Equipment, Laboratory, Optometry, Other, Out of State or Pharmacy, the HP-1 MUST be submitted to Arbitration, even if the insurance carrier or self-insured employer did not notify of an objection to the bill.

Submit this completed and signed form to the address below. Copies of the medical bill(s) must be attached. If the medical bill(s) was not for one of the types of care listed above, then copies of the written explanation of partial or non-payment (including Form C-8.4) must be attached. Additional documents may also be attached for consideration by the Arbitrator.

RETURN THIS COMPLETED AND SIGNED FORM TO:

NYS Workers' Compensation Board Medical Director's Office

Riverview Center, Suite 195, 150 Broadway

Menands, NY 12204

NUMBER OF MEDICAL BILLS ATTACHED

HP-1(2-20)

1 of 2

 

REQUEST FOR DECISION ON UNPAID

MEDICAL BILL(S)

HP-1

 

 

WCB Case Number

Name of Injured Worker (First Name, Middle Initial, Last Name)

 

 

Injured Worker's Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Injury/Illness

 

 

Insurer or Self-Insured Employer ID

 

 

 

 

 

 

Claim Administrator Claim Number (Carrier Case)

 

 

 

 

 

 

 

 

 

 

 

 

 

W

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Mailing Address of Insurer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK APPLICABLE TYPE OF CARE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Acupuncturist

 

Ambulance

 

Audiology

 

 

 

 

 

 

 

Chiropractor

 

 

 

Dental

 

Durable Medical Equipment

 

Inpatient Hospital

Laboratory

 

 

 

Licensed Clinical Social Worker

Nurse Practitioner

 

Occupational Therapist

Optometry

 

 

 

Osteopathic Physician

 

Out of State

 

Outpatient Hospital/ASC

Pharmacy

 

 

 

Physician

 

Physician Assistant

 

Physical Therapist

Podiatrist

 

 

 

Psychologist

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Provider Number (NPI)

 

 

WCB Authorization Number (if applicable)

Provider's WCB Rating Code (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal Tax ID Number

SSN

 

Total Charge ($)

 

Amount Paid ($)

 

 

 

 

 

 

 

Amount in Dispute ($)

 

 

 

 

 

 

 

 

 

 

 

 

EIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Mailing Address of Health Provider/Supplier

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

 

 

 

 

Zip Code

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

 

Name and Billing Address of Health Provider/Supplier

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

 

 

 

 

 

 

Zip Code

 

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I affirm, under penalty or perjury, that:

(1)The attached medical bill(s) was submitted to the responsible insurer/self-insured employer for payment, AND

(2)Proper payment in accordance with the applicable Fee Schedule has not been received, AND

(3)I will abide by the WCB's decision.

Date:

Health Provider/Supplier's Signature

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

Any questions regarding the completion of this form, contact the NYS Workers' Compensation Board at 1-800-781-2362

HP-1(2-20)

2 of 2

 

How to Edit Hp 1 Form Online for Free

Once you open the online editor for PDFs by FormsPal, it is possible to fill out or alter decision unpaid pdf here. To make our tool better and more convenient to utilize, we consistently come up with new features, taking into account feedback from our users. With a few basic steps, you may begin your PDF editing:

Step 1: Simply click the "Get Form Button" in the top section of this site to start up our form editor. This way, you will find everything that is required to fill out your document.

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As a way to fill out this form, be certain to enter the necessary information in every single blank:

1. It's important to fill out the decision unpaid pdf accurately, therefore take care when filling out the areas containing all these blanks:

Stage no. 1 for filling in hp 1 form

2. Once your current task is complete, take the next step – fill out all of these fields - RETURN THIS COMPLETED AND SIGNED with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

RETURN THIS COMPLETED AND SIGNED, RETURN THIS COMPLETED AND SIGNED, and RETURN THIS COMPLETED AND SIGNED in hp 1 form

3. This next step focuses on WCB Case Number, Name of Injured Worker First Name, Injured Workers Social Security, Date of InjuryIllness, Insurer or SelfInsured Employer ID, Claim Administrator Claim Number, Name of Employer, Name and Mailing Address of Insurer, Name, Address, City, CHECK APPLICABLE TYPE OF CARE, State, Zip Code, and Acupuncturist - fill out all of these fields.

Acupuncturist, Name of Injured Worker First Name, and Date of InjuryIllness in hp 1 form

It's simple to make errors while filling in your Acupuncturist, for that reason make sure to look again before you'll submit it.

4. This next section requires some additional information. Ensure you complete all the necessary fields - National Provider Number NPI, WCB Authorization Number if, Providers WCB Rating Code if, Federal Tax ID Number, SSN, EIN, Name and Mailing Address of Health, Name, Address, City, Email Address, Name and Billing Address of Health, Name, Address, and City - to proceed further in your process!

Learn how to fill out hp 1 form stage 4

5. And finally, the following final subsection is what you will need to finish before closing the PDF. The fields at this point are the next: I will abide by the WCBs decision, Health ProviderSuppliers Signature, Date, ANY PERSON WHO KNOWINGLY AND WITH, and Any questions regarding the.

Part no. 5 in filling in hp 1 form

Step 3: Always make sure that the information is accurate and then press "Done" to finish the project. Right after getting afree trial account with us, it will be possible to download decision unpaid pdf or send it via email right away. The form will also be at your disposal through your personal account page with all of your edits. We don't sell or share any details you provide when working with documents at FormsPal.

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