Utah > Workers Compensation
Medical Care Provider Application For Hearing 024 - Utah
| Medical Care Provider Application For Hearing Form. This is a Utah form and can be used in Workers Compensation . |
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Form 024 3/1/12 State of Utah - Labor Commission Division of Adjudication 160 East 300 South, 3rd Floor, P.O. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 casefiling@utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK ___________________________________________________________ Medical Care Provider (Petitioner) ___________________________________________________________ Injured Employee vs. ___________________________________________________________ Respondent (employer) ___________________________________________________________ Respondent's mailing address ___________________________________________________________ City, State and Zip Code ___________________________________________________________ Respondent's phone number ___________________________________________________________ Respondent's workers' comp Insurance Carrier* ___________________________________________________________ Insurance Carrier's mailing address ___________________________________________________________ City, State and Zip Code ___________________________________________________________ Insurance Carrier's phone number APPLICATION FOR HEARING MEDICAL CARE PROVIDER (NOTE: Include all supporting documentation when this form is filed with the Labor Commission or the Application for Hearing may be returned) I request to have a Claims Resolution Conference scheduled to resolve the issues checked below YES NO *It is the petitioner's obligation to provide the mailing address and phone number for respondent's insurance carrier. If you do not have this information you may obtain this information on the Labor Commission website, Industrial Accidents Division Workers' Compcheck or contact the employer or the Industrial Accidents Division. PETITIONER ALLEGES AND REQUESTS RESOLUTION CONCERNING THE FOLLOWING UNDER TITLE 34A: 1. 2. 3. 4. Date of industrial injury: Month____________Date________Year___________. Medical Charges at issue (you must attach an itemized, detailed account of the services rendered, the date of the services, the charges for the services, and the correct RVRBS billing code): Amounts paid by respondents to date:________________________________________________________________________________________. The injuries employee sustained from the accident are: ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ If you are billing for restorative services you must include RSA forms. 5. American LegalNet, Inc. www.FormsWorkFlow.com Form 024 3/1/12 APPLICATION FOR HEARING Petitioner verifies that the above information is true and correct to the best of petitioner's information and belief. _______________________________________________ ________________ Printed Name of Attorney for Petitioner State Bar # __________________________________________________________________ Signature of Attorney for Petitioner __________________________________________________________________ Mailing Address for Attorney for Petitioner __________________________________________________________________ City/State/Zip Code __________________________________________________________________ Telephone Number ________________________________________ ______________________ FAX E Mail Address _______________________________________ ________________________ Signature of Petitioner Date __________________________________________________________________ Mailing Address of Petitioner __________________________________________________________________ City/State/Zip Code __________________________________________________________________ Petitioner's Telephone Number __________________________________________________________________ Petitioner's Social Security Number __________________________________________________________________ Petitioner's E Mail Address If you know the name and address of the adjuster or third party administrator that you have dealt with concerning your claim please include that information: _________________________________________________________________________ Name of adjuster or third party administrator _________________________________________________________________________ Mailing Address for adjuster or third party administrator _________________________________________________________________________ City/State/Zip Code _________________________________________________________________________ E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com
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