Form Mn Ar04 - Annual Claim For Reimbursement From The Second Injury Fund Page 2
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2MEDICAL AND REHABILITATION EXPENSE DETAIL
Attach detailed description/itemization of rehabilitation and/or medical expenses. Include the dates of service, dates paid, amounts paid
and names of providers. (Computerized printouts are sufficient if they include all required information.)
These medical expenses
do NOT exceed
DO exceed permissible limits set for medical services in Minnesota Rules
Chapter 5221. If the medical fee schedule has not been applied to any bills for medical services, ATTACH A COPY OF THE BILL
SHOWING THE CPT CODE.
DATES for which you are requesting reimbursement
through
1. a. Medical and rehabilitation expenses claimed this period
b. Less deductible to this date of injury
-
SUBTOTAL
c. Percent apportioned (Attach proof of apportionment if claiming for the first time)
%
SUBTOTAL
d. Lump sum amount to be reimbursed
e. TOTAL Medical and Rehabilitation expenses claimed
$
INDEMNITY EXPENSE DETAIL
Complete an Interim Status Report for the period covered by this claim. Transfer the information from the Interim Status Report.
DATES for which you are requesting reimbursement
through
2. a. Temporary Partial Benefits paid
Retraining Benefits paid
Temporary Total Benefits paid
Permanent Total Benefits paid
SUBTOTAL
b. Less deductible to this date of injury
-
SUBTOTAL
c. Percent apportioned (Attach proof of apportionment if claiming for the first time)
%
SUBTOTAL
d. Permanent Partial, Impairment Compensation, Economic Recovery claimed
(circle type of permanency paid)
e. Lump sum to be reimbursed
f. TOTAL indemnity reimbursement claimed
$
3. TOTAL reimbursement claimed (1e + 2f)
$
SPECIAL COMPENSATION FUND USE ONLY
Indemnity Amount Approved
$
Medical Amount Approved
$
Adjustment Code
Amount Adjusted
$
Approved by
Total Approved
$
Date Approved
Paid by
Date Paid
Vendor Number
Batch Number
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