Motion To Present Additional Evidence Form. This is a Idaho form and can be use in Medical Fee Dispute Workers Compensation.
Tags: Motion To Present Additional Evidence, 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 TO MOTION TO PRESENT ADDITIONAL EVIDENCE PROVIDER, DISPUTE NO.: ____________________ GREETINGS: v. PATIENT: WE COMMAND YOU, that all business and excuses beingNO: aside, you and each of you attend before SOC. SEC. laid , the Honorable at the PAYOR. DATE(S) OFCourt SERVICE: located at County of DISPUTED AMOUNT: $ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the COMES NOW ____________________________, Movant, pursuant to Judicial Rule (B)(3)(b) as referenced in IDAPA 17002.08.032 and requests that the Industrial Commission Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the partyState of Idaho receive further evidence infor a maximum penaltyMotion and Reconsideration of the on whose behalf this subpoena was issued support of Movant’s of $50 for all damages sustained as a result of your failure to comply. filed in this matter. Witness, Honorable , one of the Justices of the Court Movant requests leave to submitof County, day additional evidence is because ____________________ , 20 1. in ___________________________________________________________________________ (Attorney must sign above and type name below) 2. Movant desires to present the following evidence: _______________________________ ___________________________________________________________________________ Attorney(s) for 3. The proposed evidence is relevant to the issue(s) before the Industrial Commission because ___________________________________________________________________________ Office and P.O. Address ___________________________________________________________________________ Telephone No.: Facsimile No.: MOTION TO PRESENT ADDITIONAL EVIDENCE - 1 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : 4. The proposed evidence was not presented to the staff because JUDICIAL SUBPOENA ______________________ Plaintiff(s) -against: ___________________________________________________________________________ : 5. Movant seeks to present this evidence by _______________________________________ : ___________________________________________________________________________ Defendant(s) : ...................................................... I certify that the information herein is true and accurate to the best of my information and belief. THE PEOPLE OF THE STATE OF NEW YORK DATED This TO Day of __________________, 20___. GREETINGS: BY: Signature of Authorized Agent 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 or adjourned date, to testify and give evidence as a witness in this action on the part of the CERTIFICATE OF SERVICE I hereby certify that on the Day of ____________ , ________, a true and correct copy of Your failure to comply with Evidence was punishable as a each of of following, as noted: this Motion to Present Additional this subpoena is served by uponcontempt thecourt 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 to comply. IDAHO INDUSTRIAL COMMISSION MEDICAL FEEHonorable COORDINATOR DISPUTE Witness, PO BOX 83720 Court in County, day of BOISE, ID 83720-0041 Other Party’s Address: US Mail Hand Delivery ________ , one of the Justices of the ________ , 20 Fax ________ US Mail ________ (Attorney must sign above and type name below) Hand Delivery ________ Fax ________ Attorney(s) for Signature of Authorized Agent Office and P.O. Address Telephone No.: Facsimile No.: MOTION TO PRESENT ADDITIONAL EVIDENCE - 2 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com