Department of Labor and Industry Workers’ Compensation Division Benefit Management and Resolution Unit PO Box 64218 St. Paul, MN 55164-0218 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Fax: (651) 284-5727 Request for Certification of Dispute PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format. C A 0 0 2 2 DO NOT USE THIS SPACE 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 workers’ 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 department’s 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 workers’ compensation court of appeals; the departments of revenue and health; and the workers’ compensation reinsurance association. WID or SSN DATE OF INJURY EMPLOYEE NAME EMPLOYER NAME INSURER/SELF-INSURER/TPA INSURER ADDRESS CITY CLAIM REPRESENTATIVE NAME INSURER CLAIM # INSURER PHONE # EXT. INSURER FAX # STATE ZIP CODE Part(s) of body injured: Have more than 3 days of work been missed because of this injury? YES NO If medical services are disputed, are they being provided or managed by a certified managed care plan? YES NO If Yes, attach information showing that the dispute procedure of the managed care plan has already been exhausted (per 176.1351, subd. 3). Nature of the rehabilitation or medical dispute (if there are unpaid medical bills, itemize below): HEALTH CARE PROVIDER NAME SERVICE DATE(S) $ AMOUNT DATE BILL SUBMITTED TO INSURER Reason insurer has denied (if known): PRINTED NAME AND TITLE PHONE # ADDRESS FAX # CITY CA0022 (5/08) STATE ZIP EXT. DATE SUBMITTED American LegalNet, Inc. www.FormsWorkflow.com