Idaho > Workers Compensation > Medical Fee Dispute
Request For Approval Of Disputed Charge - Idaho
| Request 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 THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO PROVIDER, ) ) ) v. ) ) PAYOR, ) ) ____________________) In re: PATIENT: DATE(S) OF SERVICE: DISPUTED AMOUNT: $ Comes now ___________________________, Provider, pursuant to Rule 19, JRP, and requests the Industrial Commission of the State of Idaho for an order approving the fees for health care services set forth in Appendix "A" attached hereto, which fees have been disputed. Payor REQUEST FOR APPROVAL OF DISPUTED CHARGE has 21 calendar days from the date it receives this request to file its response. Rule 19, JRP. Documents submitted in support of this request are attached hereto and included the following: 1. 2. 3. 4. 5. (Rev. 1/01/2004) Appendix 6 Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com This request is further supplemented by the attached Affidavit, which is incorporated by reference herein. See Appendix B. DATED this ________ day of ________________, 20____. ____________________________________ Provider or Agent CERTIFICATE OF SERVICE I hereby certify that on the _____ day of _______________, 20____, a true and correct copy of this Request was served on each of the following, as noted: IDAHO INDUSTRIAL COMMISSION MEDICAL FEE DISPUTE COORDINATOR PO BOX 83720 BOISE ID 83720-0041 US Mail Hand Delivery Fax _______ _______ _______ Payor's Address: US Mail Hand Delivery Fax _______ _______ _______ ___________________________ Signature Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com APPENDIX A REQUEST FOR APPROVAL OF DISPUTED CHARGE Date of Service CPT Code / Item Description (CPT Code is preferred) Amount Billed Amount Paid Amount Objected to TOTALS (expand as necessary) Appendix 6A American LegalNet, Inc. www.USCourtForms.com 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 Provider's 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, service/treatment/charge. for the same DATED This ______ day of ___________________, 20_____. _____________________________ Provider or Agent American LegalNet, Inc. www.USCourtForms.com Appendix 6B American LegalNet, Inc. www.USCourtForms.com
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