Oregon > Workers Comp > Request For Review Of Decision Or Resolution Of Dispute
Medical Fee Dispute Resolution Worksheet 2330a - Oregon
| Medical Fee Dispute Resolution Worksheet Form. This is a Oregon form and can be used in Request For Review Of Decision Or Resolution Of Dispute Workers Comp . |
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Medical Fee Dispute Workers Compensation Division Resolution Worksheet Worker information Worker name: Phone: Social Security No: Claim No: List specific codes and dates of services in dispute Service dates Code Amount Billed Amount Paid 440-2330a (9/96/DCBS/WCD/WEB) Attach copies of this sheet if more lines are needed 2330a
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