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Provider Request For Medical Fee Dispute Resolution MFDR Form 19 - Oklahoma

Provider Request For Medical Fee Dispute Resolution Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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MFDR FORM 19 OKLA. CITY, OK a on Co or er Co en 73105 Send Original to i ion and 1 o to In uran e Carrier, Self-In ured E lo er/Own Ri Grou or Unin ured E lo er In re lai of: lo ee (Clai ant) WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 THIS SPACE FOR COMMISSION USE ONLY PROVIDER REQUEST FOR MEDICAL FEE DISPUTE RESOLUTION Full Na e of Injured E E lo ee So ial Se urit Nu ber (LAST 4 DIGITS ONLY) XXX-XX-____________________________ Na e of E lo er (Re ondent) E Ri lo er In uran e Carrier, Per it # for Co Grou , Unin ured i ion A roved Individual Self-In ured or Own COMMISSION FILE NO. (Must be filled out) Na e of Provider Date of Injur (Plea e t e or rint) Addre of E lo ee (Clai ant) In luding Nu ber & Street Cit State Zi Addre of E lo er (Re ondent) In luding Nu ber & Street Cit State Zi Addre of Provider In luding Nu ber & Street Cit State Zi Provider Tele hone Nu ber NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. REQUEST FOR PAYMENT OF CHARGES FOR HEALTH OR REHABILITATION SERVICES 1. Date( ) of the ervi e( ) in di ute: ____________________________________________________________________________________________________________ 2. Pla e of ervi e: ___________________________________________________________________________________________________________________________ 3. Treat ent or ervi e ode( ) in di ute: ________________________________________________________________________________________________________ 4. A ount billed b the rovider for the treat ent( ) or ervi e( ) in di ute: $__________________________________________________________________________ 5. Date harge iden ed in Paragra h 4 were ub i ed to the wor er o en a on a or. (MUST be completed.) __________________________________________ 6. A ount aid b the wor er o en a on a or for the treat ent( ) or ervi e( ) in di ute: $__________________________________________________________ 7. Di uted a ount for ea h treat ent or ervi e in di ute (a a h addi onal age if needed): ____________________________________________________________ _______________________________________________________________________________________________________________________________________ 8. I there i a nal de i ion regarding o en abilit extent of injur liabilit and/or edi al ne e it (Che a li able o on .) Provide a o i on tate ent of the di uted i ue( ) whi h in lude : (a) the rovider rea oning for wh the di uted fee hould be aid; (b) a di u ion of how the 9. Ad ini tra ve or er Co en a on A t (A CA), or er Co en a on Co i ion rule , and/or the O laho a wor er o en a on fee hedule i a t the di uted fee i ue , in luding referen e to the e i general in tru on, ground rule or other rovi ion of the fee h edule erving a the ba i for the reque ted rei bur e ent; and (c) a di u ion of how the ub i ed do u enta on u ort the rovider o i on for ea h di uted fee i ue. (ATTACH ADDITIONAL PAGES IF NEEDED.) ___________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________ H b ". S y , y -, b y y y b y b b MFDR FORM 19 WHEN THE FORM IS FILED WITH THE COMMISSION. - ," q b y 4 y . DO NOT ATTACH ANY SUCH RECORDS OR DOCUMENTATION TO THE b , 405 5 -8760 -S 800 5 -8 0. b , I declare under PENALTY OF PERJURY that I have examined all statements contained herein, and to the best of my knowledge and belief, they are true, correct and com lete Any erson who commits workers com ensa on fraud, u on convic on, shall be guilty of a felony unishable by im risonment, a fine or both Si ned t is _______ day of __________________________________ ___________ I HEREBY CERTIFY THAT A COPY OF THIS FORM AND ALL RELEVANT RECORDS AND DOCUMENTATION, INCLUDING BILLS AND APPLICABLE MEDICAL RECORDS, HAVE BEEN SENT TO: Name of Self-Insured Employer/Own Risk Group Insurance Carrier Uninsured Employer Si nature of ro ider rint or type Name of A orney Represen n ro ider if any A orney Address (Number & Street) OA Address (Number & Street) City City State Zip Code State Zip Code elep one Number of A orney represen n ro ider if any --4 American LegalNet, Inc. www.FormsWorkFlow.com
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