Form 112 October 2016 Edition Filed: KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Medical Dispute Claim No. Before: vs. Plaintiff/Employee Defendant/Employer (business name) Social Security Number/Green Card Mailing Address Birth Date City/State/Postal Code Mailing Address Insurance Carrier City/State/Postal Code Mailing Address Country City/State/Postal Code Occupation * Date of injury / last exposure: * Cause of Injury: * Body part affected: * Nature of Injury: Medical Provider: Name Mailing Address City Medical Provider: Name Mailing Address City State Postal Code State Postal Code Medical Provider: Name Mailing Address City Medical Provider: Name Mailing Address City State Postal Code State Postal Code American LegalNet, Inc. www.FormsWorkFlow.com * Comes as follows. This party is the: Employee Employer and requests resolution of a medical dispute, and states Insurance Carrier Medical Provider * Has a workers' compensation claim been filed with the Department of Workers' Claims? Yes No If yes, please provide claim number * A utilization review has been completed. Yes No If no, please explain why a utilization review is not required by 803 KAR 25:190 in this claim: NOTE: If utilization review is required by 803 KAR 25:190, no Medical Dispute may be filed prior to exhaustion of that process. The date(s) on which each disputed statement for services was first received by the employer, insurance carrier or any agent thereof is as follows: Description Date First Received NOTE: A copy of all disputed statements for services must be attached hereto, including all required documentation. * The nature of this dispute can be briefly described as follows: (Please include all facts necessary for relief sought and attach copies of any supporting medical documentation.) * Has an award or settlement previously been entered on this claim? If yes, date of award or settlement: The following supporting documents are attached: Copy of the final utilization review decision Physician opinion supporting utilization review decision Medical bill audit, if any Copies of disputed statements for services Supporting medical documentation Yes No For reopening a claim to contest this medical treatment, the following additional items are attached: Motion to Reopen Affidavit(s) Medical report Current medical release Form 106 signed and witnessed A copy of the Opinion and Award, Settlement, Agreed Order or Agreed Resolution sought to be reopened American LegalNet, Inc. www.FormsWorkFlow.com Submitting Party: * Name * Mailing Address Mailing Address * City / State / Postal Code This information is true and accurate according to my knowledge and belief. Role Signature A copy of this filing has been sent to the following recipients: American LegalNet, Inc. www.FormsWorkFlow.com