COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers222 Compensation 633 17th Street, 4th Floor | Denver, CO 80202-3626 Phone: (303) 318-8700 | Fax: (303) 318-8758 cdlemedicalpolicy@state.co.us MEDICAL DISPUTE RESOLUTION INTAKE FORM Name of Contacting Party: Title: Mailing Address: Email Address: Phone: ( ) Fax: ( ) Provider/Payer Initiating Dispute: NPI or Tax ID#: Other Party Involved in Dispute: Claimant: Date(s) of Service: Employer: Date(s) of Injury: Disputed amount: Payment you received: $ Payment you believe you should have received: $ Explain how you arrived at this amount: Have you followed the procedures in Rule 16 - 12(D)? Yes No If not, why? Issue(s) in Dispute (check all that apply): Rule UCR CPT256 Supply PPO Contract Other Briefly explain the dispute: What actions have you taken to resolve this dispute? (I nclude person(s) you spoke with and date ( s ) if available) Please attach all applicable supporting documents: Original bill Office/procedure/operation notes EOB(s)/EOR(s) Call logs/emails Prior authorization Correspondence from other party Invoice(s) Copy of request for contract Appeal(s) WC 181 Rev. 0 3 /18 American LegalNet, Inc. www.FormsWorkFlow.com