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Request For Approval Of Disputed Charge Form. This is a Idaho form and can be use in Medical Fee Dispute Workers Compensation.
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Tags: Request For Approval Of Disputed Charge, Idaho Workers Compensation, Medical Fee Dispute
Name of party Submitting
_________________________________
Address of party Submitting
_________________________________
Phone of party Submitting
BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO
PROVIDER,
)
)
)
v.
)
)
PAYOR,
)
)
____________________)
REQUEST FOR APPROVAL OF
DISPUTED CHARGE
In re:
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 21 calendar days from the date it receives this request to file
its response.
Rule 19, JRP.
Documents submitted in support of this request are attached
hereto and included the following:
1.
2.
3.
4.
5.
(Rev. 1/01/2004)
Appendix 6
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This request is further supplemented by the attached Affidavit,
which is incorporated by reference herein.
See Appendix B.
DATED this ________ day of ________________, 20____.
____________________________________
Provider or Agent
CERTIFICATE OF SERVICE
I
hereby
certify
that
on
the
_____
day
of
_______________,
20____, a true and correct copy of this Request was served on each of
the following, as noted:
IDAHO INDUSTRIAL COMMISSION
MEDICAL FEE DISPUTE COORDINATOR
PO BOX 83720
BOISE ID 83720-0041
_______
Hand Delivery
_______
Fax
Payor's Address:
US Mail
_______
US Mail
_______
Hand Delivery
_______
Fax
_______
___________________________
Signature
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APPENDIX A
REQUEST FOR APPROVAL OF DISPUTED CHARGE
Date of
Service
CPT Code / Item Description
(CPT Code is preferred)
TOTALS
Amount
Billed
Amount
Paid
Amount
Objected to
(expand as necessary)
Appendix 6A
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APPENDIX B
AFFIDAVIT OF USUAL AND CUSTOMARY
I, ___________________________, hereby attest and certify
that:
1.
I have personal knowledge of the information stated in this
Affidavit, and it is true and accurate to the best of my
information and belief.
2.
The charges listed in Appendix A arose from medical services
for an industrial injury under the Idaho Workers’
Compensation law.
3.
The charges listed in Appendix A are this Provider’s most
frequent charge(s) for the item(s) listed.
4.
These charges are the same for all patients, whether
industrially injured or not.
5.
Attached hereto, or set out below, is:
_____
(check one)
an accurate copy of our standard fee schedule for
the items in Appendix A, (or)
_____
bills for other patients, non-industrially injured,
for the same
service/treatment/charge.
DATED This ______ day of ___________________, 20_____.
_____________________________
Provider or Agent
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Appendix 6B
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