Reset Form PROVIDER FEE REQUEST FOR ASSISTANCE State Form 52875 (R / 11-14) INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, Indiana 46204 Telephone: (317) 232-3808 Toll free: (800) 824-COMP * This agency is requesting disclosure of the employee's Social Security Number in accordance with 631 IAC 1-1-32; disclosure is voluntary and you will not be penalized for refusal. INSTRUCTIONS: 1. 2. Please print or type. Return completed request to the address listed above. PROVIDER INFORMATION EMPLOYER INFORMATION Name of employer Address (number and street) City, state, and ZIP code National Provider Identification number (NPI) Amount owed Telephone number Name of provider Address (number and street) City, state, and ZIP code Telephone number ( ) Date(s) of service (month, day, year) ( Total bill Balanced bill ) County of employment Date(s) billing / claim submitted to carrier / TPA (month, day, year) Date initial written communication received after bill submission (month, day, year) Name of employee treated / provided services Social Security Number of employee * Have you hired an attorney? If Yes, name and telephone number of attorney WORKER'S COMPENSATION INSURANCE / THIRD PARTY ADMINISTRATOR (TPA) INFORMATION Name of company Name of adjustor Insurance claim number Telephone number ( ) Contact person(s) Briefly describe your complaint / dispute (Attach claim forms submitted.) I hereby request the medical claims reviewer of the Worker's Compensation Board to investigate my complaint. I understand that the medical claims reviewer is not a replacement for legal counsel, and that any specific legal questions should be addressed to my attorney. Signature of authorized representative Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com