PDF
Word
Form WCB-190A Provider's Petition for Payment of Medical and Related Services - Maine
What Is Form WCB-190A?
This is a legal form that was released by the Maine Workers' Compensation Board - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the Form WCB-190A?
A: The Form WCB-190A is the Provider's Petition for Payment of Medical and Related Services.
Q: What is the purpose of the Form WCB-190A?
A: The purpose of the Form WCB-190A is for medical providers to petition for payment of services provided to injured workers.
Q: Who can use the Form WCB-190A?
A: Medical providers in the state of Maine can use the Form WCB-190A.
Q: What information is required on the Form WCB-190A?
A: The Form WCB-190A requires information such as the injured worker's name, date of injury, description of services provided, and the amount being claimed.
Form Details:
- Released on October 1, 2015;
- The latest edition provided by the Maine Workers' Compensation Board;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form WCB-190A by clicking the link below or browse more documents and templates provided by the Maine Workers' Compensation Board.
