Pennsylvania > Workers Comp
Request For Hearing To Contest Fee Review Determination LIBC-606 - Pennsylvania
| Request For Hearing To Contest Fee Review Determination Form. This is a Pennsylvania form and can be used in Workers Comp . |
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Commonwealth of Pennsylvania Department of Labor & Industry Workers' Compensation Office of Adjudication 1010 North 7th Street, Room 318 Harrisburg, PA 17102 REQUEST FOR HEARING TO CONTEST FEE REVIEW DETERMINATION INSURER OR THIRD PARTY ADMINISTRATOR (if self-insured) NAME: _____________________________________________ ADDRESS: __________________________________________ ADDRESS: __________________________________________ CITY: _____________________ STATE:_____ ZIP:_________ COUNTY: ___________________________________________ TELEPHONE: ________________________________________ BUREAU CODE: ______________________________________ PROVIDER NAME: __________________________________________ ADDRESS: _______________________________________ ADDRESS: _______________________________________ CITY: ______________________ STATE:_____ ZIP:_____ COUNTY: ________________________________________ TELEPHONE: ____________________________________ PATIENT/EMPLOYEE FIRST NAME:______________________________________ LAST NAME: ______________________________________ INJURY DATE: ____________________________________ BUREAU CLAIM NO:_______________________(if known) INS. CLAIM NO.: ______________ FEIN: __________________ EMPLOYER NAME:________________________________________________ ADDRESS: ____________________________________________ CITY/TOWN: __________________STATE:_______ZIP:________ THIS REQUEST IS BEING FILED BY: HEALTH CARE PROVIDER INSURER /EMPLOYER FEE REVIEW APPLICATION NUMBER(S) AND DATE OF FEE REVIEW DETERMINATION(S): Application Number: Application Number: Application Number: Determination Date: Determination Date: Determination Date: TO THE FEE REVIEW HEARING OFFICE: I hereby request a de novo hearing by a Fee Review Hearing Officer under 34 Pa. Code ยง127.257 in the above-referenced Fee Review Application(s). a. The following bills are disputed: BILLING FORM DATE OF BILL SERVICE DATE PROC/SVC CODE AMOUNT BILLED LIBC-606 06-11 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com b. The following factual issues relative to the medical payment matter are in dispute. (Concisely state all factual issues. Do not attach supplemental pages.) c. The following legal issues are in dispute. (Concisely cite the specific statutory and regulatory authority asserted to be relevant and/or applicable in this matter. Do not attach supplemental pages.) I hereby certify that on this day I have mailed a copy of this Request for Hearing to all parties and their attorneys, if known, including the provider whose bills are the subject of this review. Requesting Party or Representative FIRST NAME: _________________________ LAST NAME: ____________________ Signature: _______________________________________ Date: ______/______/_______ MM DD YYYY NOTICE: All Requests for Hearing will be returned if not signed and dated. Do not attach documents to this request. The Workers' Compensation Office of Adjudication will destroy all attachments and will NOT process them or return them to you. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-606 06-11 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com
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