When a Louisiana carrier denies a 1010 request for treatment, approves it with modifications, or fails to answer within five business days, the aggrieved party can ask the OWCA Medical Director to review the decision on this form. It is also how a party seeks a variance from the Medical Treatment Schedule. Disputes over compensability or causation are not handled here.
The aggrieved party completes the form: the employee, the employee's attorney, or the health care provider, marked in item 7. The requesting party signs and prints their name.
Download the current version from the source each time; forms change without notice.
Disputed Claim for Medical Treatment (1009)
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15 calendar days from the 1010 denial, approval with modification, or deemed denial. A deemed denial happens when the carrier or self-insured employer fails to return the 1010 within five business days after the provider submits it.
Yes. Item 7 lets the request be submitted by the employee or the employee's attorney, the health care provider, or another party. By signing, the requester certifies that the form and all supporting documents were sent to the carrier or self-insured employer the same day by email or fax.