Name of party Submitting Address of party Submitting Phone of party Submitting BEFORE THE INDUSTRIAL COMMISSION OF THE STATE OF IDAHO PROVIDER, v. RESPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE PAYOR. COMES NOW PATIENT: SOC. SEC. NO: DATE(S) OF SERVICE: , Payor, pursuant to Judicial Rule XIX, Judicial Rules of Practice and Procedure, and responds to the Motion for Approval of Disputed Charge filed by Payor in this matter. (Insert argument and discussion here. Payor should include any appropriate discussion. Payor should also submit any affidavits or documents in support of its response). DATED this day of , 20 . Signature of Authorized Agent RESPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 1 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I hereby certify that on the Day of , , a true and correct copy of this Motion for Approval of Disputed Charge 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 Other Party's Address: US Mail Hand Delivery Fax Signature of Authorized Agent RESPONSE TO MOTION FOR APPROVAL OF DISPUTED CHARGE - 2 American LegalNet, Inc. www.FormsWorkFlow.com