Medical Dispute {112}

Form 112 - MEDICAL DISPUTE. This form is used to initiate or respond to a medical dispute in a workers’ compensation claim. The form can be filed by an employee, employer, insurance carrier, or medical provider. It requires claim details such as date, cause, nature, and body part affected, along with any involved medical providers. Before filing, a utilization review (per 803 KAR 25:190) must generally be completed unless an exemption applies. The form documents disputed medical services or bills, prior awards or settlements, and requires supporting documentation such as medical reports, utilization review decisions, and physician opinions. For reopening a claim, additional filings such as a Motion to Reopen, affidavits, and Form 106 (medical release) are required. www.FormsWorkflow.com