Form MAO October 1, 2005 COMMONWEALTH OF KENTUCKY OFFICE OF WORKERS’ CLAIMS CLAIM NO. __________ _____________________________ PLAINTIFF VS. _____________________________ _____________________________ DEFENDANT(S) MEDICAL FEE DISPUTE & MEDIATION AGREED ORDER I. MEDICAL FEE DISPUTE RESOLUTION A. Type of challenged or unpaid procedure ____ 1. Multiple ____ 2. Prescription medication ____ 3. Pain management ____ 4. Medical office visits ____ 5. Appliances or prostheses ____ 6. Chiropractic treatment ____ 7. Physical therapy ____ 8. Surgery ____ 9. Home Health /attendant care ____ 10. Diagnostic testing ____ 11. Mileage reimbursement for medical treatment ____ 12. Other (specify):_________________________________________ ______________________________________________________ B. Basis for Challenge ____ 1. Multiple ____ 2. Reasonableness / necessity of procedure or charge ____ 3. Utilization of medical services ____ 4. Utilization of prescription medication ____ 5. Causation / work-relatedness ____ 6. Form 113 referral ____ 7. Refusal to authorize or pay for medical services ____ 8. Other (specify): ________________________________________ ______________________________________________________ American LegalNet, Inc. www.USCourtForms.com II. RESOLVED MEDICAL FEE DISPUTE ISSUES The following issues have been resolved: _____________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ III. UNRESOLVED MEDICAL FEE DISPUTE ISSUES The following issues remain unresolved and will be referred to the Frankfort Motion Docket for the entry of the appropriate order: ___________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ IV. FINAL RESOLUTION _____ 1. Dispute fully resolved – Form 112 dismissed _____ 2. Unresolved issues – referred to Frankfort Motion Docket V. DISPUTED AMOUNT _____ _____ _____ _____ _____ 1. 2. 3. 4. 5. less than $500 $500 - $1000 $1000 – 2000 $2000 – above N/A Date: _________________________________, 200__. ____________________________________ ADMINISTRATIVE LAW JUDGE / MEDIATOR Have seen and agreed: _______________________________ Plaintiff’s Attorney ______________________________ _______________________________ Defendant/Employer’s Attorney ______________________________ _______________________________ ______________________________ American LegalNet, Inc. www.USCourtForms.com