Idaho > Workers Compensation > Medical Fee Dispute
Motion To Present Additional Evidence - Idaho
| Motion To Present Additional Evidence Form. This is a Idaho form and can be used in Medical Fee Dispute Workers Compensation . |
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______________________ Name of party Submitting ______________________ Address of party Submitting ______________________ Phone of party Submitting BEFORE T HE INDUSTRIAL COMMISSION OF THE STAT E OF IDAHO MOTION TO PRESENT ADDITIONAL EVIDENCE PROVIDER, DISPUTE NO.: ____________________ v. PATIENT: SOC. SEC. NO: PAYOR. DATE(S) OF SERVICE: DISPUT ED AMOUNT: $ COMES NOW ____________________________, Movant, pursuant to Judicial Rule (B)(3)(b) as referenced in IDAPA 17002.08.032 and requests that the Industrial Commission of the State of Idaho receive further evidence in support of Movants Motion for Reconsideration filed in this matter. 1. Movant requests leave to submit additional evidence is because ____________________ ________________________________________________________________________ ___ 2. Movant desires to present the following evidence: _____________________ __________ ________________________________________________________________________ ___ 3. The proposed evidence is relevant to the issue(s) before the Industrial Commission because ________________________________________________________________________ ___ ________________________________________________________________________ ___ MOTION TO PRESENT ADDITIONAL EVIDENCE - 1 <<<<<<<<<********>>>>>>>>>>>>> 24. The proposed evidence was not presented to the staff because ______________________ ________________________________________________________________________ ___ 5. Movant seeks to present this evidence by _______________________________ ________ ________________________________________________________________________ ___ I certify that the information herein is true and accurate to the best of my information and belief. DATED This Day of __________________, 20___. BY: Signature of Authorized Agent CERTIFICATE OF SERVICE I hereby certify that on the Day of ____________ , ________, a true and correct copy of this Motion to Present Additional Evidence was served by upon each of the following, as noted: IDAHO INDUSTRIAL COMMISSION US Mail ________ MEDICAL FEE DISPUTE COORDINATOR Hand Delivery ________ PO BOX 83720 BOISE, ID 83720-0041 Fax ________ Other Partys Address: US Mail ________ Hand Delivery ________ Fax ________ Signature of Authorized Agent MOTION TO PRESENT ADDITIONAL EVIDENCE - 2
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