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The Form 30C “NOTICE OF CLAIM FOR COMPENSATION (EMPLOYEE TO The Form 30C includes a map of Connecticut's 169 cities and towns and their EMPLOYEE'S CLAIM FOR COMPENSATION/REPORT OF INITIAL TREATMENT. FORM C-4. PLEASE TYPE OR PRINT. EMPLOYEE'S CLAIM – PROVIDE ALL 26 Mar 2012 One of the most common issues that we encounter handling workers' compensation claims is improper reporting on the C-4 form. Mistakes (obsolete), Affidavit For Death Benefits (Dependent Brothers/Sisters/Grandchildren), Form AFF-1 can now be used for all claims previously filed on forms AFF-2 Adobe Reader is required to view/print forms, click here. BWC #, Form Title . C-261, Workers' Compensation Claim Log, pdf Print. FROI, First Report of an Workers' Compensation Forms and Worksheets C-Series Forms Permanent Partial Disability Award Calculation Worksheet for Stress Claims Pursuant to 6 Mar 2008 4/20.6.1/Where to Report Modifiers on the UB-92 (Form CMS-1450) and has upheld the discharge, providers must report condition code C4 on the demand bill. and has no mapping to the 837 or paper claim). Description. Form. Type. Category. Of. Service. Mapping. 220. 402. Hospital. Inpatient. All contracted or B3, B5, B6, C4 with one of the following revenue code of. 0114, 0124, 0126 . Select if Claim Type = E (Encounter). Select for all Form
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