Minnesota > Workers Comp
Medical Request MQ03 - Minnesota
| Medical Request Form. This is a Minnesota form and can be used in Workers Comp . |
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CHECK BOX IF THIS REQUEST ADDS MEDICAL ISSUES TO A PENDING MEDICAL REQUEST WID or SSN Medical Request PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT NOTE: Before filing this form, call the workers' compensation insurer. If that does not resolve the issue, call the Workers' Compensation Alternative Dispute Resolution Unit at (651) 284-5032 (or 1-800-342-5354). DATE OF INJURY M0 Q3 DO NOT USE THIS SPACE EMPLOYEE NAME PHONE # (include area code) EMPLOYEE ADDRESS INSURER/SELF-INSURER/TPA CITY STATE ZIP CODE INSURER ADDRESS EMPLOYER NAME CITY STATE ZIP CODE EMPLOYER ADDRESS CLAIM REPRESENTATIVE NAME CITY STATE ZIP CODE INSURER CLAIM # INSURER PHONE # EXT INSTRUCTIONS: · This form must be filled out completely; otherwise, it may be returned to you. · The injured worker's name, WID or social security number, and date of injury must be written on all attached documents. · This form may not be used to request wage loss, vocational rehabilitation, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Alternative Dispute Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee's Employee Attorney YES NO Employer Insurer/TPA Self-insured Insurer's Attorney Health Care Provider 2. 3. Are medical services being provided or managed by a certified managed care plan? YES NO If yes, attach information showing that the dispute resolution process of the certified managed care plan has already been exhausted. MEDICAL ISSUES (check only those that apply) I request: a. that health care provider bills be paid. (List all health care providers whose bills or services are in dispute. Attach extra sheets if needed. Itemized bills and supporting medical reports must be attached.) NAME ADDRESS UNPAID BALANCE b. a change of treating doctor: FROM: TO: NAME NAME ADDRESS ADDRESS SPECIALTY SPECIALTY c. that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting medical reports.) d. that the employee's medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports. e. a second opinion or consultation with NAME SPECIALTY f. other (explain): MN MQ03 (4/12) (over) American LegalNet, Inc. www.FormsWorkFlow.com IF YOU DO NOT COMPLETE SECTION 4 ENTIRELY, WE WILL NOT BE ABLE TO PROCESS YOUR REQUEST. 4. HAS ANYONE OTHER THAN THE WORKERS' COMPENSATION INSURER PAID HEALTH CARE PROVIDER BILLS RELATED TO THIS DISPUTE? YES NO If yes, bills were paid by: Medicare NAME employee Veterans Administration Dept. of Human Services (Welfare) other POLICY NUMBER Social Security Administration ADDRESS private health insurance In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary. 5. Explain the details of your request. Attach all documents, such as medical reports and bills, and also identify any applicable treatment parameter or other rule that support(s) your request. A decision may be based solely on these documents, the Workers' Compensation Division file, and the response to this form. 6. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, attorneys, and any party named in #4 above who has paid medical expenses. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE NAME NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE I sent a copy of this form and all attachments to the parties listed in #6 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE (date) ADDRESS ATTORNEY REGISTRATION # CITY STATE ZIP CODE PHONE # (include area code) EXT DATE SIGNED WHEN YOU HAVE FULLY COMPLETED THIS FORM, RETURN IT AND ALL ATTACHMENTS TO: In Person: MN Department of Labor and Industry Workers' Compensation Division 443 Lafayette Road N. St. Paul, MN 55155-4301 Mailing Address: MN Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 Fax: 651-284-5731 Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers' compensation dispute. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers' compensation court of appeals; the departments of revenue and health; and the workers' compensation reinsurance association. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com 443 Lafayette Road N. St. Paul, Minnesota 55155 www.dli.mn.gov (651) 284-5005 1-800-DIAL-DLI TDD: (651) 297-4198 Instructions for Completing a Medical Request Form Use a Medical Request form if you want to resolve a dispute about a workers' compensation medical issue. Do not use a Medical Request if you have a dispute about rehabilitation, wage loss or permanent partial disability issues. Do not use the Medical Request if the insurer has denied primary liability for the entire claim (denial of primary liability). You must use an Employee's Claim Petition in this case. Item 3 on the front of the Medical Request form lists the most common medical issues in dispute. Here are some guidelines to help you put your dispute in a category. a. I request that the insurer pay medical or chiropractic bills. An injured worker may request the insurer pay medical or chiropractic bills if the insurer has accepted liabil
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