File this form with the Department of Labor and Industry at the address or fax number at the end of this form. THIS FORM RESPONDS TO ISSUES RAISED ON Medical Response PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT Reset MR03 DO NOT USE THIS SPACE THE MEDICAL REQUEST FORM SIGNED ON (date) WID or SSN DATE OF INJURY 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: All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. This form must be filled out completely. The injured worker222s name, WID or social security number, and date of injury must be written on all attached documents. You must complete this response form and send it to the address on the back of this form within 20 days of the date you received the Medical Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Altern ative Dispute Resolution Unit at (651) 284 - 5032 or 1 - 800 - 342 - 5354. YES NO 1. THIS RESPONSE IS BEING COMPLETED BY: Employee Employee222s Attorney Employer Insurer/TPA Self-insured Insurer222s Attorney Health Care Provider 2. The employee has not exhausted the dispute resolution process of the certified managed care plan. The employee may contact at (phone) to initiate this process. Name of the Certified Managed Care Plan 3. RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I respond to the request for payment of medical or chiropractic bills as follows: (List the health care providers and your response to the specific bill amounts listed on the Request form. Attach extra sheets if needed). HEALTH CARE PROVIDER ALREADY PAID AGREE TO PAY REFUSE TO PAY b. I agree disagree with the request to change treating doctors. c. I agree refuse to pay for the requested treatment, surgery or equipment. d. I agree refuse to reimburse the employee for medical expenses. e. I agree disagree with the request for a second opinion or consultation. f. MN MR03 (6/18) (over) Response to 223Other224: American LegalNet, Inc. www.FormsWorkFlow.com YOU MUST COMPLETE # 4 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 4. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely upon review of this form, its attachments, the Workers222 Compensation Division file, and the Medical Request form . Specify any applicable treatment parameter(s): Minn. Rule 5221. 5. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, and attorneys. 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 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 #5 on (date) PRINT NAME OF PERSON FILING THIS RESPONSE 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