Workers Compensation Medical Provider Information
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NOTICE
Attention Medical Provider
Your Insurance Company became impaired, triggering the Texas Property and Casualty Insurance Guaranty Association. The Texas Property and Casualty Insurance Guaranty Association can not verify that we are in receipt of this claim file at this time. We anticipate receipt of the claim files in the near future. Unfortunately, we do not usually receive payment histories or the records we receive are incomplete and this necessitates the need for an affidavit. Upon receipt of the claim file and confirmation of coverage, your bill will be processed. Completion of this affidavit in no way guarantees payment, but is required for your bill to be considered. Therefore, we need your assistance. Please complete the following affidavit so that we may consider your bill for payment. Please return the notarized affidavit with the bill(s) to our office by mail, including any documentation. Each date of service must be accompanied by a properly completed medical bill in accordance with the Texas Workers’ Compensation Commission’s rules and regulations. Only dates of service prior to your Insurance Company’s date of impairment require an affidavit.
We will not accept faxed bills.
Download the Affidavit in Adobe PDF or MS Word 2002
Thank you for your assistance.