Request For Certification Of Dispute {CA0022}

CA0022 - ATTORNEY REQUEST FOR CERTIFICATION OF DISPUTE. This form is used in Minnesota’s workers’ compensation system when an attorney, on behalf of an injured employee, seeks certification from the Department of Labor and Industry that a dispute exists between the employee and the employer or insurer. This form is typically filed in cases involving disagreements over medical services, rehabilitation services, or unpaid medical bills. It requires detailed information about the employee, employer, insurer, claim representative, and the nature of the dispute, including itemized billing details, service dates, amounts, and any reasons provided by the insurer for denial of payment. If medical services are managed by a certified managed care plan, proof that the plan’s dispute resolution process has been completed must also be attached. Once submitted, the Department reviews the request and may certify the dispute, which allows the matter to move forward to a formal resolution process through the Court of Administrative Hearings or other appropriate channels. www.FormsWorkflow.com