Motion For Reconsideration Form. This is a Idaho form and can be use in Medical Fee Dispute Workers Compensation.
Tags: Motion For Reconsideration, Idaho Workers Compensation, Medical Fee Dispute
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : ______________________ Name of party Submitting : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : ______________________ Address of party Submitting : ______________________ Defendant(s) Phone of party Submitting : ...................................................... BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO THE PEOPLE OF THE STATE OF NEW YORK MOTION FOR RECONSIDERATION TO DISPUTE NO.: ____________________ PROVIDER, v. GREETINGS: PATIENT: SOC. SEC. NO: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before PAYOR. DATE(S) OF SERVICE: , the Honorable at the Court DISPUTED AMOUNT: $ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed COMES NOW ____________________________, Movant, pursuant to Judicial Rule or adjourned date, to testify and give evidence as a witness in this action on the part of the (B)(3)(a) as referenced in IDAPA 17002.08.032 and requests that the Industrial Commission Your failure to comply with this subpoena Order on Motion for Approval of Disputed of the State of Idaho review the Administrativeis punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure tomatter. This Motion is based on the Administrative Order, pleadings and Charge filed in this comply. , one of the Justices exhibitsWitness, Honorable filed with the Commission in this matter, and on other information relied on by of the Court in County, day of , 20 Commission staff. If filed herewith, this Motion is also based on the Motion to Present Additional Evidence and on the information and evidence filed in support of the type name below) (Attorney must sign above and Motion. Movant requests that the Industrial Commission review the Administrative Order for the following reasons: 1. Attorney(s) for __________________________________________________________________________ Office and P.O. Address __________________________________________________________________________ MOTION FOR RECONSIDERATION - 1 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 2. Index No. Calendar No. : __________________________________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) -against: __________________________________________________________________________ 3. : __________________________________________________________________________ : __________________________________________________________________________ Defendant(s) : . .4.. . .__________________________________________________________________________ . ................................................ __________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK 5. __________________________________________________________________________ TO __________________________________________________________________________ I certify that the information herein is true and accurate to the best of my information and belief. GREETINGS: DATED This Day of __________________, 20___. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed BY: or adjourned date, to testify and give evidence as a witness in this action on the part of the Signature of Authorized Agent Your failure to comply with CERTIFICATEpunishable as a contempt of court and will make you liable to this subpoena is OF SERVICE the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a I hereby certify that Day of ____________ , ________, a true and correct result of your failure to comply.on the copy of this Administrative Order was served by upon each of the following, as noted: Witness, Honorable Court in County, , one of the Justices of the day of , 20 IDAHO INDUSTRIAL COMMISSION MEDICAL FEE DISPUTE COORDINATOR PO BOX 83720 BOISE, ID 83720-0041 US Mail ________ Hand Delivery ________ Other Party’s Address: US Mail Fax (Attorney must sign above and type name below) ________ Attorney(s) for ________ Hand Delivery ________ Fax ________ Office and P.O. Address Signature of Authorized Agent MOTION FOR RECONSIDERATION - 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com