Name of party Submitting Address of party Submitting Phone of party Submitting BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO MOTION FOR RECONSIDERATION PROVIDER, v. PAYOR. COMES NOW DISPUTE NO.: PATIENT: SOC. SEC. NO: DATE(S) OF SERVICE: DISPUTED AMOUNT: $ , Movant, pursuant to Judicial Rule 19 (E)(3)(a) as referenced in IDAPA 17.02.09.034 and requests that the Industrial Commission of the State of Idaho review the Administrative Order on Motion for Approval of Disputed Charge filed in this matter. This Motion is based on the Administrative Order, pleadings and exhibits filed with the Commission in this matter, and on other information relied on by 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 Motion. Movant requests that the Industrial Commission review the Administrative Order for the following reasons: 1. MOTION FOR RECONSIDERATION - 1 American LegalNet, Inc. www.FormsWorkFlow.com 2. 3. 4. 5. I certify that the information herein is true and accurate to the best of my information and belief. DATED This Day of , 20 . BY: Signature of Authorized Agent CERTIFICATE OF SERVICE I hereby certify that on the Day of , , a true and correct copy of this Administrative Order was served by 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 MOTION FOR RECONSIDERATION - 2 American LegalNet, Inc. www.FormsWorkFlow.com