Montana > Workers Compensation
Medical Provider Billing Request - Montana
|Medical Provider Billing Request Form. This is a Montana form and can be used in Workers Compensation .||
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Medical Provider Billing Request Medical providers seeking billing information must send a request via e-mail, Fax, Internet or letter that must include all of the following: Date of request: Medical Provider Information Name of Requestor (your name) Name of Business (medical provider name) Phone Number Fax Number Mailing Address Claimant Information Social Security Number (must be 9 digits) Legal Name (as it appears on SS card) Date of Injury (exact month/day/year) Part of Body Injured Name of Employer Address City (must be exact) We can not comply with your request unless all the above fields are completed. FOR ERD OFFICE USE ONLY Claim number Adjuster Name Adjuster Address Adjuster phone number Could Not Respond due to one of the following reasons: No Claims for this date of injury No Claims for this SS# and name No Coverage for this date of injury Employer is not on the system Other: For access to the ERD Medical Provider Billing In formation System send written requests to the Medical Provider Hotline, Claims Assistance Bureau, PO Box 8011, Helena, MT 59624; fax requests to: Medical Provider Hotline at (406) 444-4140, electronically mail requests to email@example.com. To expedite your request please use this form.