Medical Provider Billing Request Medical providers seeking billing information, send a request via letter, fax, or e-mail. Include all of the following: Date of request: Medical Provider Information Name of Requestor (your name) Name of Business (medical provider name) Phone Number Fax Number Mailing Address Claimant Information Social Security Number (must be 9 digits) Legal Name (as it appears on SS card) Date of Injury (exact month/day/year) Part of Body Injured Name of Employe r Address City We can not comply with your request unless all the above fields are completed. FOR ERD OFFICE USE ONLY Claim number Adjuster Name Adjuster Address Adjuster phone number Could Not Respond due to one of the following reasons: No Claims for this date of injury No Claims for this SS# and name No Coverage for this date of injury Employer is not on the system Other: Send written requests to: Loraine Hovland, Claims Assistance Bureau, PO Box 8011, Helena, MT 59624 Fax requests to: Loraine Hovland at (406) 444-4140 (Voice: 406-444-6543) E-mail requests to: dlierdbp&s@mt.gov Please use this form to expedite your request. American LegalNet, Inc. www.FormsWorkFlow.com