Kentucky > Workers Comp
Medical Dispute 112 - Kentucky
| Medical Dispute Form. This is a Kentucky form and can be used in Workers Comp . |
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Form 112 DEPARTMENT OF WORKERS CLAIMS Medical Dispute 657 TO BE ANNOUNCED AVENUE Revised 6/26/00 FRANKFORT, KENTUCKY 40601 Claim No. _________________ MEDICAL DISPUTE Movant Respondent ____________________________ vs. ___________________ ___________ Name Name __________________________________ _____________________________________ Street Address Street Address __________________________________ _____________________________________ City, State, Zip Code City. State, Zip Code * * * * * * * * * * * * * * * * * * * * * * Patient: Employer: ____________________________________ ________________________________ Name & Social Security Number Name ________________________ __ _________ ________________________________ Street Address Date of Injury Street Address _____________________________ _______________________________ City, State, Zip Code City. State, Zip Code Medical Payment Obligor: Counsel for Movant: _____________________________ ________________________________ Name Name _____________________________ ________________________________ Street Address Street Address _____________________________ ________________________________ City, State, Zip Code City. State, Zip Code Medical Provider: Medical Provider: __________________________ ___ _________________________________ Name Name _____________________________ _________________________________ Street Address Street Address _____________________________ _________________________________ City, State, Zip Code City. State, Zip Code Medical Provider: Medical Provider: _____________________________ __________________________________ Name Name _____________________ ________ __________________________________ Street Address Street Address _____________________________ __________________________________ City, State, Zip Code City. State, Zip Code * * * * * * * * * * * * * * * * * * * * * Comes the movant and requests resolution of a medical dispute, and states as follows: 1. A workers compensation claim has _____ has not ______ been filed with the Department of Workers Claims. 2. Utilization review and medical bill audit have been completed. A copy of the final utilization review decision with supporting physician opinions is attached. Yes__ No__ <<<<<<<<<********>>>>>>>>>>>>> 2 Note: If utilization review is required by 803 KAR 25:190, no Medical Dispute may be filed prior to exhaustion of that process. 3. Utilization review is not required by 803 KAR 25:190 in this claim because (state specific reason):_________________________________ ________________________ ______________________________________________________________________ 4. The date on which each disputed statement for services was first received by the payment obligor or any agent thereof is ____________________, 20____. 5. Copies of all disputed statements for services are attached hereto, including all required documentation. Yes ________ No __________ 6. The nature of this dispute can be briefly described as follows: (Please include all facts necessary for relief sought and attach copies of any supporting medical documentation). _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ This information is true and accurate according to my knowledge and belief. ___________________________________ ____ Movants Signature Subscribed and sworn to before me this _______ day of ____________, 20_____ ____________________________________ Notary Public Signature My Commission Expires: ______________________ Note: The respondent and all other parties have 20 days in which to file a response pursuant to 803 KAR 25:012. Copies of responses must be delivered to the Commissioner of the Department of Workers Claims and to all parties. Certificate of Service As required by 803 KAR 25:012, copies must be served on all parties, including the employee, employer, medical payment obligor, and the medical provider(s). I certify that true copies of this form and all attachments have been deposited in the United States mail today to the Commissioner of the Department of Workers Claims, 657 To Be Announced Avenue, Frankfort, Kentucky, 40601, and to the following individuals or entities: (Please list names and addresses) 1. _______________________________________________________ __________ 2. _________________________________________________________________ 3. _________________________________________________________________ 4. _________________________________________________________________ 5. ___________________________ ______________________________________ 6. _________________________________________________________________ Date:________________ _______________________________________________ Movants Signature <<<<<<<<<********>>>>>>>>>>>>> 3 NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
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