________________________________ Name of party Submitting _________________________________ Address of party Submitting _________________________________ Phone of party Submitting BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO ) ) ) v. ) ) ___________________ ) Payor. ) _________________________) ___________________ Provider, MOTION FOR APPROVAL OF DISPUTED CHARGE 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 has twenty-one (21) calendar days from the date it receives this request to file its response. Rule 19, JRP. Documents submitted in support of this motion are attached hereto and include the following: 1. 2. 3. 4. 5. DATED this ________ day of ________________, 20____. ________________________________ Provider or Agent ________________________________ Print or Type Name Page 1 of 2 Appendix 6A Appendix A (List of Disputed Charges) American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I hereby certify that on the _____ day of _______________, 20____, a true and correct copy of this Motion was served upon 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 _______ _______ _______ ______________________________________ Provider or Agent Signature _______________________________________ Print or Type Name Page 2 of 2 ­ Appendix 6A American LegalNet, Inc. www.FormsWorkFlow.com APPENDIX A MOTION 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 6B American LegalNet, Inc. www.FormsWorkFlow.com