CHECK BOX IF THIS REQUEST ADDS MEDICAL ISSUES TO A PENDING MEDICAL REQUEST Medical Request PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT NOTE: File this form with the Department of Labor and Industry at the address or fax number at the end of this form. Before filing this form, call the workers222 compensation insurer or the Workers222 Compensation Alternative Dispute Resolution Unit at (651) 284-5032 or 1-800-342-5354. MQ03 DO NOT USE THIS SPACE WID or SSN DATE OF INJURY Reset EMPLOYEE NAME PHONE # (include area code) EMPLOYEE ADDRESS INSURER/SELF-INSURER/TPA CITY STATE ZIP CODE INSURER ADDRESS EMPLOYER NAME CITY STATE ZIP CODE EMPLOYER ADDRESS CLAIM REPRESENTATIVE NAME CITY STATE ZIP CODE INSURER CLAIM # INSURER PHONE # EXT INSTRUCTIONS: 225 This form must be filled out completely; otherwise, it may be returned to you. 225 The injured worker222s name, WID or social security number, and date of injury must be written on all attached documents. 225 This form may not be used to request wage loss, vocational rehabilitation, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Alternative Dispute Resolution Unit at (651) 284 - 5032 or 1 - 800 - 342 - 5354. YES NO 1. THIS REQUEST IS BEING COMPLETED BY: Employee Employee222s Attorney Employer Insurer/TPA Self-insured Insurer222s Attorney Health Care Provider 2. Are medical services being provided or managed by a certified managed care plan? YES NO If yes, attach information showing that the dispute resolution process of the certified managed care plan has already been exhausted. 3. MEDICAL ISSUES (check only those that apply) I request: a. that health care provider bills be paid. (List all health care providers whose bills or services are in dispute. Attach extra sheets if needed. Itemized bills and supporting medical reports must be attached.) NAME ADDRESS UNPAID BALANCE b. a change of treating doctor: FROM: NAME ADDRESS SPECIALTY TO: NAME ADDRESS SPECIALTY c. that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting medical reports.) d. that the employee222s medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports. e. a second opinion or consultation with f. MN MQ03 (6/18) (over) other (explain): NAME SPECIALTY American LegalNet, Inc. www.FormsWorkFlow.com IF YOU DO NOT COMPLETE SECTION 4 ENTIRELY, WE WILL NOT BE ABLE TO PROCESS YOUR REQUEST. 4. HAS ANYONE OTHER THAN THE WORKERS222 COMPENSATION INSURER PAID HEALTH CARE PROVIDER BILLS RELATED TO THIS DISPUTE? YES NO If yes, bills were paid by: employee Veterans Administration Dept. of Human Services (Welfare) Medicare Social Security Administration private health insurance other In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary. NAME ADDRESS POLICY NUMBER 5. Explain the details of your request. Attach all documents, such as medical reports and bills, and also identify any applicable treatment parameter or other rule that support(s) your request. A decision may be based solely on these documents, the Workers222 Compensation Division file, and the response to this form. 6. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, attorneys, and any party named in #4 above who has paid medical expenses. Provide the names and addresses below. Attach extra sheets if necessary. NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE I sent a copy of this form and all attachments to the parties listed in #6 on (date) PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE ADDRESS ATTORNEY REGISTRATION # CITY STATE ZIP CODE PHONE # (include area code) EXT DATE SIGNED WHEN YOU HAVE FULLY In Person: Mailing Address: Fax: COMPLETED THIS FORM, MN Department of Labor and Industry MN Department of Labor and Industry 651 - 284 - 5731 RETURN IT AND ALL Workers222 Compensation Division Workers222 Compensation Division ATTACHMENTS TO: 443 Lafayette Road N. PO Box 64221 St. Paul, MN 55155 - 4301 St. Paul, MN 55164 - 0221 Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers222 compensation dispute. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department222s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers222 compensation court of appeals; the departments of revenue and health; and the workers222 compensation reinsurance association. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS222 COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com 443 Lafayette Road N. (651) 284 - 5005 St. Paul, MN 55155 1 - 800 - 342 - 5354 www.dli.mn.gov Instructions for completing a Medical Request form Submit a Medical Request form if you want to resolve a dispute about a workers' compensation medical issue. You must file the Medical Request form with the Department of Labor and Industry (department) at the address or fax number at the end of the form. Do not file the Medical Request with the Office of Administrative Hearings (OAH) 226 the department will send the Medical Request to OAH when OAH has jurisdiction under the workers222 compensation law. The department may also send the dispute to OAH when authorized by law. Do not use a Medical Request form if you also have a dispute about rehabilitation, wage loss or permanent partial disability or if the insurer has denied primary liability for the entire workers222 compensation claim (denial of primary liability). In these cases you must use an Employee's Claim Petition form. Item 3 on the front of the Medical Request form lists the most common medical issues in dispute. Here are some guidelines to help you put your dispute in a category. a. I request that the insurer pay medical or chiropractic bills. An injured worker may request the insurer pay medical or chiropractic bills if the insurer has accepted liability for the claim, but is denying payment for any reason. A health care provider may file a request on this issue if there is a dispute about the reasonableness and necessity of their services or about the amount billed. A health care provider should not submit this form if the issue is whether the work injury was responsible for the workers' need for treatment. Do not submit this form unless the insurer has had 30 days to review the bills or has already refused to pay. b. I request a change of treating doctor. The injured worker or the employer/insurer may request a change of doctor. Make sure to fill in the name of the current treating doctor and the name of the doctor whom you want as the primary health care provider. If the employee and insurer agree on a change of doctor, you do not need to file this form. c. I request that prescribed treatment, surgery or equipment be provided. Check this issue if your doctor has prescribed treatment, surgery or equipment but the insurer has not agreed to pay for it. Enclose a copy of a doctor's report stating why you need the treatment, surgery or equipment. If a prescription expense is disputed, include a copy of the prescrip