Name of party Submitting Address of party Submitting Phone of party Submitting BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO MOTION TO PRESENT ADDITIONAL EVIDENCE DISPUTE NO.: v. PATIENT: SOC. SEC. NO: DATE(S) OF SERVICE: DISPUTED AMOUNT: $ , Movant, pursuant to Judicial Rule 19 PROVIDER, PAYOR. COMES NOW (E)(3)(b) as referenced in IDAPA 17.02.09.034 and requests that the Industrial Commission of the State of Idaho receive further evidence in support of Movant's Motion for Reconsideration filed in this matter. 1. Movant requests leave to submit additional evidence is because 2. Movant desires to present the following evidence: 3. The proposed evidence is relevant to the issue(s) before the Industrial Commission because MOTION TO PRESENT ADDITIONAL EVIDENCE - 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. The proposed evidence was not presented to the staff because 5. Movant seeks to present this evidence by 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 Motion to Present Additional Evidence was served by upon each of the following, as noted: IDAHO INDUSTRIAL COMMISSION MEDICAL FEE DISPUTE COORDINATOR PO BOX 83720 BOISE, ID 83720-0041 Other Party's Address: US Mail Hand Delivery Fax US Mail Hand Delivery Fax Signature of Authorized Agent MOTION TO PRESENT ADDITIONAL EVIDENCE - 2 American LegalNet, Inc. www.FormsWorkFlow.com