Idaho > Workers Compensation > Medical Fee Dispute
Response To Motion For Approval Of Disputed Charge - Idaho
| Response To Motion For Approval Of Disputed Charge 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 RESPONS E TO MOTION FOR PROVIDER, APPROVAL OF DISP UTE D CHARGE v. PATIENT: SOC. SEC. NO: PAYOR. DATE(S) OF SERVICE: COMES NOW ____________________________, Payor, pursuant to Judicial Rule XIX, Judicial Rules of Practice and Procedure, and responds to the Motion for Approval of Disputed Charge filed by Payor in this matter. (Insert argument and discussion here. Payor should include any appropriate discussion. Payor should also submit any affidavits or documents in support of its response). DATED this _________ day of _______________________, 200__. ____________________________________ Signature of Authorized Agent REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 1 <<<<<<<<<********>>>>>>>>>>>>> 2 CERTIFICATE OF SERVICE I hereby certify that on the Day of ____________ , ________, a true and correct copy of this Motion for Approval of Disputed Charge 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 REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 2 <<<<<<<<<********>>>>>>>>>>>>> 3 APPENDIX A MOTION FOR APPROVAL OF DISPUTED CHARGE Date of CPT Code / Item Description Amount Amount Amount Service (CPT Code is preferred) Billed Paid Objected to REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 3 <<<<<<<<<********>>>>>>>>>>>>> 4 APPENDIX B AFFIDAVIT OF USUAL AND CUSTOMARY I, ___________________________, hereby attest and certify that: 1. I have personal knowledge of the information stated in this Affidavit, and it is true and accurate to the best of my information and belief. 2. The charges listed in Appendix A arose from medical services for an industrial injury under the Idaho Workers Compensation law. 3. The charges listed in Appendix A are this Providers most frequent charge(s) for the item(s) listed. 4. These charges are the same for all patients, whether industrially injured or not. 5. Attached hereto, or set out below, is: (check one) _____ an accurate copy of our standard fee schedule for the items in Appendix A, (or) _____ bills for other patients, non-industrially injured, for the same service/treatment/charge. DATED This ______ day of ___________________, ___________. ___________________________________ Authorized Agent REPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 4
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