North Dakota > Workers Comp
Provider Request For An Adjustment SFN 58310 - North Dakota
| Provider Request For An Adjustment Form. This is a North Dakota form and can be used in Workers Comp . |
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PROVIDER REQUEST FOR AN ADJUSTMENT MEDICAL SERVICES DIVISION SFN 58310 (01/2009) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-866-356-6433 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com INJURED WORKER INFORMATION Patient's Name Bill Number Claim Number CMS 1500 REASON FOR REQUEST Medical Notes Attached Underpayment Retro Review (complete explanation section below) UB Requesting reconsideration for payment (complete explanation section below) PROVIDER INFORMATION Provider's Name City Federal Tax ID Number State Check Number Provider's Address Zip PAYMENT INFORMATION Remittance Advice Date DATES OF SERVICE UNITS FROM THRU PLACE OF SERVICE PROCEDURE/ANCILLARY/ ACCOMODATION CODE MODIFIER TOOTH NUMBER SURFACE AMOUNT BILLED AMOUNT PAID TOTAL Explanation/Comments: (retro review please submit supporting medical documentation) Contact Name Date Phone Number M6 American LegalNet, Inc. www.FormsWorkFlow.com
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